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Li C, Hu Y, Li S, Yi X, Shao S, Yu W, Li E. Biological factors controlling starch digestibility in human digestive system. FOOD SCIENCE AND HUMAN WELLNESS 2023. [DOI: 10.1016/j.fshw.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Кузнецов КО, Михеева АЮ, Ишмухаметова АА, Толстых ТА, Галляметдинова АР, Ботирова ЗУ, Забирова АА, Шарипова АШ, Шайхлисламова АБ, Абрахманова ДР. [Diabetic gastroenteropathy: modern methods of diagnosis and treatment]. PROBLEMY ENDOKRINOLOGII 2022; 68:67-78. [PMID: 36337020 PMCID: PMC9762451 DOI: 10.14341/probl13082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/14/2022] [Accepted: 07/13/2022] [Indexed: 11/09/2022]
Abstract
Diabetes mellitus is a chronic disease with a growing prevalence worldwide, however, the prevalence of its complications, including gastroenteropathy, is also increasing. The pathophysiology of diabetic gastroenteropathy (DH) combines hyperglycemia, vagus nerve dysfunction, decreased expression of nitric oxide synthase in the myenteric plexus, changes in the interstitial Cajal cell network, as well as oxidative stress. Clinical signs of DH are gastroesophageal reflux, gastroparesis, constipation, abdominal pain and diarrhea. Among the diagnostic methods are manometry with pH measurement (assessment of esophageal motility), gastric emptying scintigraphy, respiratory test (to assess gastroparesis), aspiration and cultivation of the contents of the jejunum (to diagnose bacterial overgrowth syndrome). To date, there is no definitive treatment for DH - an interdisciplinary approach is aimed at slowing the progression of the disease, relieving symptoms and restoring gastrointestinal function. Patients are recommended a diet low in simple sugars and high in fiber; optimization of glycemic control with a target glycemia of less than 180 mg/dl. As for drug therapy, the use of prokinetics and antiemetics is justified, and in case of excessive bacterial growth syndrome, antibacterial therapy (rifaximin) is carried out. Modern approaches to the treatment of DH are also accumulating, including the use of botulinum toxin, pyloroplasty and electrical stimulation of the stomach in individual patients. Despite the constant development of new treatments, they are not yet able to completely cure DH in the near future, which makes it necessary to conduct further research in this area.
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Affiliation(s)
- К. О. Кузнецов
- Российский национальный исследовательский медицинский университет им. Н.И. Пирогова
| | - А. Ю. Михеева
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - А. А. Ишмухаметова
- Первый Московский государственный медицинский университет им. И.М. Сеченова
| | - Т. А. Толстых
- Первый Московский государственный медицинский университет им. И.М. Сеченова
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Reijnders TDY, Peters-Sengers H, van Vught LA, Uhel F, Bonten MJM, Cremer OL, Schultz MJ, Stuiver MM, van der Poll T. Effect of erythromycin on mortality and the host response in critically ill patients with sepsis: a target trial emulation. Crit Care 2022; 26:151. [PMID: 35610649 PMCID: PMC9128233 DOI: 10.1186/s13054-022-04016-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Immunomodulatory therapies that improve the outcome of sepsis are not available. We sought to determine whether treatment of critically ill patients with sepsis with low-dose erythromycin-a macrolide antibiotic with broad immunomodulatory effects-decreased mortality and ameliorated underlying disease pathophysiology. METHODS We conducted a target trial emulation, comparing patients with sepsis admitted to two intensive care units (ICU) in the Netherlands for at least 72 h, who were either exposed or not exposed during this period to treatment with low-dose erythromycin (up to 600 mg per day, administered as a prokinetic agent) but no other macrolides. We used two common propensity score methods (matching and inverse probability of treatment weighting) to deal with confounding by indication and subsequently used Cox regression models to estimate the treatment effect on the primary outcome of mortality rate up to day 90. Secondary clinical outcomes included change in SOFA, duration of mechanical ventilation and the incidence of ICU-acquired infections. We used linear mixed models to assess differences in 15 host response biomarkers reflective of key pathophysiological processes from admission to day 4. RESULTS In total, 235 patients started low-dose erythromycin treatment, 470 patients served as controls. Treatment started at a median of 38 [IQR 25-52] hours after ICU admission for a median of 5 [IQR 3-8] total doses in the first course. Matching and weighting resulted in populations well balanced for proposed confounders. We found no differences between patients treated with low-dose erythromycin and control subjects in mortality rate up to day 90: matching HR 0.89 (95% CI 0.64-1.24), weighting HR 0.95 (95% CI 0.66-1.36). There were no differences in secondary clinical outcomes. The change in host response biomarker levels from admission to day 4 was similar between erythromycin-treated and control subjects. CONCLUSION In this target trial emulation in critically ill patients with sepsis, we could not demonstrate an effect of treatment with low-dose erythromycin on mortality, secondary clinical outcomes or host response biomarkers.
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Affiliation(s)
- Tom D. Y. Reijnders
- grid.509540.d0000 0004 6880 3010Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hessel Peters-Sengers
- grid.509540.d0000 0004 6880 3010Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Lonneke A. van Vught
- grid.509540.d0000 0004 6880 3010Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Fabrice Uhel
- grid.509540.d0000 0004 6880 3010Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,grid.414205.60000 0001 0273 556XAP-HP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, 92700 Colombes, France ,grid.508487.60000 0004 7885 7602Université de Paris, UFR de Médecine, 75018 Paris, France ,grid.465541.70000 0004 7870 0410INSERM U1151, CNRS UMR 8253, Institut Necker-Enfants Malades, 75015 Paris, France
| | - Marc J. M. Bonten
- grid.7692.a0000000090126352Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands ,grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf L. Cremer
- grid.7692.a0000000090126352Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcus J. Schultz
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands ,grid.10223.320000 0004 1937 0490Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand ,grid.4991.50000 0004 1936 8948Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martijn M. Stuiver
- grid.509540.d0000 0004 6880 3010Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Tom van der Poll
- grid.509540.d0000 0004 6880 3010Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,grid.7177.60000000084992262Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Meling S, Bertoli D, Sangnes DA, Brock C, Drewes A, Ejskjaer N, Dimcevski G, Søfteland E. Diabetic Gastroenteropathy: Soothe the Symptoms or Unravel a Cure? Curr Diabetes Rev 2022; 18:e220321192412. [PMID: 34225633 DOI: 10.2174/1573399817666210322154618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/13/2021] [Indexed: 11/22/2022]
Abstract
Autonomic neuropathy in patients with diabetes mellitus, and especially complications related to gastrointestinal neuropathy, are often overlooked in the clinic. Diabetic gastroenteropathy affects every segment of the gastrointestinal tract and generates symptoms that may include nausea, early satiety, vomiting, abdominal pain, constipation, and diarrhea. Severe cases can be complicated by weight loss, dehydration, and electrolyte disturbances. The pathophysiology is complex, the diagnostics and treatment options are multidisciplinary, and there is generally a lack of evidence for the treatment options. The aims for this review are first to summarize the pathophysiology and describe possible and expected symptoms and complications.Further, we will try to supply the clinician with a straightforward tool for diagnostics, and then, we shall summarize established treatment options, including diet recommendations, pharmacological and non-pharmacological options. Finally, we will explore the multiple possibilities of novel treatment, looking at medications related to the pathophysiology of neuropathy, other manifestations of autonomic neuropathies, and symptomatic treatment for other gastrointestinal disorders, also including new knowledge of endosurgical and neuromodulatory treatment. The overall goal is to increase awareness and knowledge on this frequent diabetic complication and to provide better tools for diagnosis and treatment. Ultimately, we hope to encourage further research in this field, as there are clear shortcomings in terms of biomarkers, pathophysiology, as well as treatment possibilities. In conclusion, diagnosis and management of diabetic gastroenteropathy are challenging and often require multidisciplinary teams and multimodal therapies. Treatment options are sparse, but new pharmacological, endoscopic, and neuromodulatory techniques have shown promising results in initial studies.
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Affiliation(s)
- Sondre Meling
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Davide Bertoli
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Dag A Sangnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Asbjørn Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Hwang S, Jung DH, Jwa EK, Kim Y. Preemptive pyloroplasty for iatrogenic vagus nerve injury in intrahepatic cholangiocarcinoma patients undergoing extensive left-sided lymph node dissection. Yeungnam Univ J Med 2021; 39:235-243. [PMID: 34902957 PMCID: PMC9273145 DOI: 10.12701/yujm.2021.01550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/17/2021] [Indexed: 11/14/2022] Open
Abstract
Background Intrahepatic cholangiocarcinoma (ICC) of the left liver often shows left-sided lymph node (LN) metastasis. If gastric lesser curvature is extensively dissected, it can induce an iatrogenic injury to the extragastric vagus nerve branches that control motility of the pyloric sphincter and lead to gastric stasis. To cope with such LN dissection-associated gastric stasis, we performed pyloroplasty preemptively. The objective of this study was to analyze our 20-year experience of preemptive pyloroplasty performed in 10 patients. Methods We investigated clinical sequences of 10 patients with ICC who underwent preemptive pyloroplasty following left hepatectomy and extended left-sided LN dissection. Incidence of gastric stasis and oncological survival outcomes were analyzed. Results All 10 patients were classified as stage IIIB due to T1-3N1M0 stage according to the 8th edition of American Joint Committee on Cancer staging system. The overall patient survival rate was 51.9% at 1 year, 25.9% at 2 years, and 0% at 3 years. Seven patients showed uneventful postoperative recovery after surgery. Two patients suffered from gastric stasis, which was successfully managed with supportive care. One patient suffered from overt gastric paresis, which was successfully managed with azithromycin administration for 1 month. Conclusion We believe that preemptive pyloroplasty is an effective surgical option to prevent gastric stasis in patients undergoing extensive left-sided LN dissection. Azithromycin appears to be a potent prokinetic agent in gastroparesis.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Kyoung Jwa
- Division of Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yumi Kim
- Division of Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Dai F, Guo J, Wang Y, Jiang T, Chen H, Hu Y, Du J, Xia X, Zhang Q, Shen B. Enhanced Store-Operated Ca 2+ Signal of Small Intestinal Smooth Muscle Cells Accelerates Small Bowel Transit Speed in Type 1 Diabetic Mouse. Front Physiol 2021; 12:691867. [PMID: 34744757 PMCID: PMC8564290 DOI: 10.3389/fphys.2021.691867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
Aims: The underlying mechanism of diabetic enteropathy, a common complication of type 1 diabetes, remains unclear. Store-operated Ca2+ entry (SOCE) is a ubiquitous type of Ca2+ influx involved in various cellular functions. Here, we show that SOCE-related stromal interaction molecule 1 (STIM1) and Orai1 participate in inappropriate cellular Ca2+ homeostasis, augmenting agonist-induced small intestinal smooth muscle contraction and small bowel transit speed in a mouse model of type 1 diabetes. Methods and Results: We used small interfering (si)RNA to suppress STIM1 and Orai1 proteins, and employed intracellular Ca2+, small intestinal contraction and intestinal transit speed measurement to investigate the functional change. We found that SOCE activity and Orai1 and STIM1 expression levels of small intestinal smooth muscle were significantly increased in cells cultured in high glucose medium or in diabetic mice. Gastrointestinal transit speed and SOCE-mediated contractions were markedly increased in diabetic mice; Knocking down Orai1 or STIM1 with siRNA rescued both alterations in diabetic mice. However, the Orai1-large conductance Ca2+-activated K+ (BKCa) channel interaction was decreased in diabetic mice, and suppressing Orai1 expression or inhibiting the BKCa channel increased agonist-induced small intestinal contractions in normal mice. Conclusion: We concluded that the increased SOCE caused by excessive STIM1 and Orai1 expression and decreased Orai1-BKCa interaction augmented small intestinal smooth muscle contraction and accelerated small bowel transit speed in diabetic mice. This finding demonstrates a pathological role for SOCE in diabetic enteropathy and provides a potential therapeutic target for diabetic enteropathy.
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Affiliation(s)
- Fang Dai
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jizheng Guo
- School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Yang Wang
- School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Tian Jiang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hongbo Chen
- Department of Obstetrics and Gynecology, Maternal and Child Health Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Ying Hu
- School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Juan Du
- School of Basic Medicine, Anhui Medical University, Hefei, China
| | - Xianming Xia
- Digestive Medicine Center, Department of General Practice, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Qiu Zhang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Bing Shen
- School of Basic Medicine, Anhui Medical University, Hefei, China
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Concepción Zavaleta MJ, Gonzáles Yovera JG, Moreno Marreros DM, Rafael Robles LDP, Palomino Taype KR, Soto Gálvez KN, Arriola Torres LF, Coronado Arroyo JC, Concepción Urteaga LA. Diabetic gastroenteropathy: An underdiagnosed complication. World J Diabetes 2021; 12:794-809. [PMID: 34168729 PMCID: PMC8192258 DOI: 10.4239/wjd.v12.i6.794] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/28/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
This article is an extensive review that provides an update on the pathophysiology, symptoms, diagnosis, and treatment of diabetic gastroenteropathy. There is no reported prevalence, but it has been described that patients with type 1 diabetes have a cumulative incidence at 10 years of 5.2%, and type 2 patients, 1%. Also, in the group of type 1 diabetes, it has been observed that women are more likely to present this condition (5.8% vs 3.5%). Many factors are associate with its development (e.g., hyperglycemia, vagal dysfunction, loss of expression of neural nitric oxide synthase in the myenteric plexus, alterations in the Cajal interstitial cell network, and oxidative stress). Gastrointestinal discomfort could be perceived 70% higher in diabetic patients, describing that 25% of diabetic patients experience gastrointestinal symptoms. Diabetic enteropathy could affect any portion of the gastrointestinal tract, but esophageal alterations were described in more than 60% of diabetic patients, also 60% of them present constipation, and 20%, diarrhea. Gastric emptying scintigraphy is useful to evaluate gastroparesis, therefore, gastric retention of more than 60% at 2 h has a sensitivity of 100% and specificity of 20% for diagnosis; however, other studies such as breath tests, with a sensitivity of 89% and a specificity of 80%, or the endoscopic capsule contribute to the diagnosis. There is no cure; however, management must be multidisciplinary, focused on slowing the progression of diabetic gastroenteropathy, reducing symptoms, and restoring function; that includes nutritional recommendation, maintain glucose levels kept below 180 mg/dL, use of prokinetics, anti-emetics; nowadays, it has been special interest in surgical treatment, such as pyloroplasty, also gastric electrical stimulation appears to be another alternative.
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Functional syndromes and symptom-orientated aftercare after esophagectomy. Langenbecks Arch Surg 2021; 406:2249-2261. [PMID: 34036407 PMCID: PMC8578083 DOI: 10.1007/s00423-021-02203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/16/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. PURPOSE The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. CONCLUSIONS Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.
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Vogt M, Schulz B, Wagdi A, Lebert J, van Belle GJ, Christoph J, Bruegmann T, Patejdl R. Direct optogenetic stimulation of smooth muscle cells to control gastric contractility. Am J Cancer Res 2021; 11:5569-5584. [PMID: 33859764 PMCID: PMC8039938 DOI: 10.7150/thno.53883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/12/2021] [Indexed: 12/21/2022] Open
Abstract
Rationale: Antral peristalsis is responsible for gastric emptying. Its failure is called gastroparesis and often caused by dysfunction of enteric neurons and interstitial cells of Cajal (ICC). Current treatment options, including gastric electrical stimulation, are non-satisfying and may improve symptoms but commonly fail to restore gastric emptying. Herein, we explore direct optogenetic stimulation of smooth muscle cells (SMC) via the light-gated non-selective cation channel Channelrhodopsin2 (ChR2) to control gastric motor function. Methods: We used a transgenic mouse model expressing ChR2 in fusion with eYFP under the control of the chicken-β-actin promoter. We performed patch clamp experiments to quantify light-induced currents in isolated SMC, Ca2+ imaging and isometric force measurements of antral smooth muscle strips as well as pressure recordings of intact stomachs to evaluate contractile responses. Light-induced propulsion of gastric contents from the isolated stomach preparation was quantified in video recordings. We furthermore tested optogenetic stimulation in a gastroparesis model induced by neuronal- and ICC-specific damage through methylene blue photo-toxicity. Results: In the stomachs, eYFP signals were restricted to SMC in which blue light (460 nm) induced inward currents typical for ChR2. These depolarizing currents led to contractions in antral smooth muscle strips that were stronger than those triggered by supramaximal electrical field stimulation and comparable to those evoked by global depolarization with high K+ concentration. In the intact stomach, panoramic illumination efficiently increased intragastric pressure achieving 239±46% (n=6) of the pressure induced by electrical field stimulation and triggered gastric transport. Within the gastroparesis model, electric field stimulation completely failed but light still efficiently generated pressure waves. Conclusions: We demonstrate direct optogenetic stimulation of SMC to control gastric contractility. This completely new approach could allow for the restoration of motility in gastroparesis in the future.
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Shaikh N, Nainthramveetil MM, Nawaz S, Hassan J, Shible AA, Karic E, Singh R, Al Maslamani M. Optimal dose and duration of enteral erythromycin as a prokinetic: A surgical intensive care experience. Qatar Med J 2021; 2020:36. [PMID: 33447536 PMCID: PMC7802089 DOI: 10.5339/qmj.2020.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Enteral feeding has various advantages over parenteral feeding in critically ill patients. Acutely ill patients are at risk of developing enteral feeding intolerance. Prokinetic medications improve gastrointestinal mobility and enteral feed migration and absorption. Among the available prokinetic agents, erythromycin is the most potent. Erythromycin is used in different dosages and durations with variable efficacy. Intravenous erythromycin has an early and high rate of tachyphylaxis; hence, enteral route is preferred. Recently, the combination of prokinetic medications has been increasingly used because they accelerate the prokinetic action and decrease the adverse effects. AIM This study aimed to determine the optimal effective prokinetic dose and duration of administering enteral erythromycin in combination with metoclopramide in critically ill patients. PATIENTS AND METHODS This study has a prospective observation design. After obtaining permission from the medical research center of the institution, all patients in the surgical and trauma intensive care unit having enteral feed intolerance and those who were already on metoclopramide for 24 hour (h) were enrolled in the study. Patients' demographic data, diagnosis, surgical intervention, disease severity scores, erythromycin dose, duration of administration, any adverse effects, factors affecting erythromycin response, and outcome were recorded. All patients received 125 mg syrup erythromycin twice daily through a nasogastric tube (NGT). The NGT was clamped for 2 h, and half amount of previous enteral feeds was resumed. If the patient did not tolerate the feeds, the erythromycin dose was increased every 24 h in the increment of 250, 500, and 1000 mg (Figure 1). Statistical significance was considered at P < 0.05. A total of 313 patients were enrolled in the study. Majority of the patients were male, and the mean age was 45 years. RESULTS Majority (48.2%) of the patients (96) with feed intolerance were post laparotomy. Ninety percent (284) of the patients responded to prokinetic erythromycin therapy, and 54% received lower dose (125 mg twice daily). In addition, 14% had diarrhea, and none of these patients tested positive for Clostridium difficile toxin or multidrug resistance bacteria. The mean duration of erythromycin therapy was 4.98 days. The most effective prokinetic dose of erythromycin was 125 mg twice daily (P = 0.001). Erythromycin was significantly effective in patients with multiple organ dysfunction and shock (P = 0.001). Patients with high disease severity index and multiple organ dysfunction had significantly higher mortality (p < 0.05). Patients not responding to erythromycin therapy also had a significant higher mortality (p = 0.001). CONCLUSION Post-laparotomy patients had high enteral feed intolerance. Enteral erythromycin in combination with metoclopramide was effective in low dose and was required for short duration. Patients who did not tolerate feeds despite increasing dose of erythromycin had higher mortality.
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Affiliation(s)
- Nissar Shaikh
- Surgical Intensive care, Hamad Medical Corporation, Doha, Qatar E-mail:
| | | | - Shoaib Nawaz
- Surgical Intensive care, Hamad Medical Corporation, Doha, Qatar E-mail:
| | - Jazib Hassan
- Surgical Intensive care, Hamad Medical Corporation, Doha, Qatar E-mail:
| | - Ahmed A Shible
- Clinical Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Edin Karic
- Critical Care, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Wong SW, Fogaren T. Supportive Care for Patients with Systemic Light Chain Amyloidosis. Hematol Oncol Clin North Am 2020; 34:1177-1191. [PMID: 33099432 DOI: 10.1016/j.hoc.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Light chain amyloidosis is a disease in which clonal plasma cells produce toxic immunoglobulin light chains that form amyloid fibrils with deposition in organs, most commonly the heart and kidneys, but also the nervous system, gastrointestinal tract, and soft tissues. Treatment directed at the clonal cells eliminates light chain production and further deposition and may enable organ improvement and decrease the risk of organ failure. Supportive care manages the symptoms of organ involvement and the side effects of treatment. Supportive care also addresses the psychological and social issues that may arise in patients with light chain amyloidosis.
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Affiliation(s)
- Sandy W Wong
- Hematology/Blood and Marrow Transplantation, Comprehensive Amyloid Program, University of California, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Teresa Fogaren
- Division of Hematology/Oncology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
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Ali Shah SA, Nadeem M, Jameel M, Yasmin R, Afsar A, Riaz F. Oral Erythromycin Improves the Quality of Endoscopy in Upper Gastrointestinal Bleeding Patients. Cureus 2020; 12:e10204. [PMID: 33042657 PMCID: PMC7534507 DOI: 10.7759/cureus.10204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Upper gastrointestinal bleeding is a life-threatening emergency. Endoscopy is the therapeutic and diagnostic procedure of choice after initial stabilization of the patient. But the presence of retained blood, blood products, and other residual material in the stomach is a big challenge for endoscopists during urgent endoscopy after acute upper gastrointestinal bleeding. Intravenous erythromycin before endoscopy improves the visualization of gastric and duodenal mucosa in these patients. Use of oral erythromycin is more easy and convenient, so the objective of our study was to assess the effects of oral erythromycin on quality of endoscopy in upper gastrointestinal bleeding patients. Methods This interventional study was conducted at the Department of Medicine, POF Hospital Wah Cantt, Pakistan from January 2019 to December 2019. Patients with clinical evidence of acute upper gastrointestinal bleeding within 12 hours were inducted consecutively. Patients were randomly assigned to erythromycin (500 mg) suspension or placebo, orally three hours before endoscopy. One endoscopist performed all the procedures with the same double-channel video endoscope. The primary endpoint was endoscopic quality. The secondary endpoints were the need for second-look endoscopy within 48 hours, endoscopy related complications, therapeutic procedure performed or not during endoscopy, number of blood transfusions, and length of hospital stay. Results A total of 60 patients were included in the study; 30 received erythromycin and 30 received placebo. Out of these, 60% were male and 40% were female. The mean age was 53.68 ± 16.64. Quality of endoscopy was much better in the erythromycin group (83.3%) as compared to placebo (40%). Erythromycin did not shorten the endoscopic duration (15.53 vs. 14.33 minutes in the placebo group; p=0.216) and length of hospital stay (5.23 in erythromycin vs. 5.40 days in placebo group; p=0.807). Statistically no significant association was found between use of erythromycin and establishment of cause of bleed, need for second-look endoscopy, number of blood transfusions and number of endoscopic therapeutic procedures. Conclusion Erythromycin oral suspension before endoscopy in patients with acute upper gastrointestinal bleeding produced good quality of endoscopy in our study. It improved the visualization of gastric and duodenal mucosa significantly. However, it did not shorten the duration of endoscopy or hospital stay. There was no significant difference in number of second-look endoscopies and blood transfusions as well.
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Affiliation(s)
| | | | | | | | - Anum Afsar
- Medicine, Wah Medical College, Wah Cantt, PAK
| | - Faiza Riaz
- Medicine, Wah Medical College, Wah Cantt, PAK
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Gray KD, Ullmann TM, Elmously A, Beninato T, Fahey TJ, Pomp A, Zarnegar R, Afaneh C. Treatment Utilization and Socioeconomic Disparities in the Surgical Management of Gastroparesis. J Gastrointest Surg 2020; 24:1795-1801. [PMID: 31292891 DOI: 10.1007/s11605-019-04294-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 06/03/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastroparesis is an end-organ sequela of diabetes. We evaluated the roles of race and socioeconomic status in hospitalization rates and utilization of surgical treatments in these patients. METHODS Data was extracted from the National Inpatient Sample (NIS) between the years 2012 and 2014, and any discharge diagnosis of gastroparesis (536.3) was included. Gastrostomy, jejunostomy, and total parenteral nutrition were considered nutritional support procedures, and procedures aimed at improving motility were considered definitive disease-specific procedures: pyloroplasty, endoscopic pyloric dilation, gastric pacemaker placement, and gastrectomy. RESULTS There were 747,500 hospitalizations reporting a discharge diagnosis of gastroparesis. On multivariable analysis, black race (OR 1.93, 95% CI 1.89-1.98; p < 0.001) and Medicaid insurance (OR 1.46, 95% CI 1.42-1.50; p < 0.001) were the strongest socioeconomic risk factors for hospitalization due to gastroparesis. Patients in urban teaching institutions were most likely to undergo a surgical intervention for gastroparesis (5.53% of patients versus 3.94% of patients treated in urban non-teaching hospitals and 2.38% of patients in rural hospitals; p < 0.001). Uninsured patients were less than half as likely to receive treatment compared to those with private insurance (OR 0.41, 95% CI 0.34-0.48; p < 0.001), and black patients had an OR 0.75 (95% CI 0.69-0.81; p < 0.001) for receiving treatment. Urban teaching hospitals had a twofold higher likelihood of intervention (OR 2.12, 95% CI 1.84-2.44; p < 0.001). CONCLUSIONS Marked racial and economic disparities exist in surgical distribution of care for gastroparesis, potentially driven by differences in utilization of care.
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Affiliation(s)
- Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Adham Elmously
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Alfons Pomp
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Cheguevara Afaneh
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA.
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Abstract
Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.
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Affiliation(s)
- A Sullivan
- Homerton University Hospital, London, UK
| | | | - A Ruban
- Department of Surgery and Cancer, Imperial College, London, UK.
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15
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Khalifa IG, Tobar WL, Hegazy TO, Balamoun HA, Mikhail S, Salman MA, Elsayed EA. Food Tolerance After Laparoscopic Sleeve Gastrectomy with Total Antral Resection. Obes Surg 2020; 29:2263-2269. [PMID: 30895506 DOI: 10.1007/s11695-019-03840-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among the controversial points in laparoscopic sleeve gastrectomy (LSG) is how much of the antrum to be resected. This study aimed to evaluate food tolerance after preservation or resection of the antrum during LSG. METHODS Prospective randomized study included 50 patients scheduled for LSG. Participants were randomly allocated into one of two groups. In antral resection (AR-LSG) group (n = 25), resection started 2 cm from the pylorus. In antral sparing (AS-LSG) group (n = 25), it started 6 cm from the pylorus. Percentage of excess weight loss (%EWL) and percentage of excess BMI loss (%EBL) were evaluated after 3 and 6 months. Quality of life (QOL) was evaluated by using the Bariatric Analysis and Reporting Outcome System (BAROS). Food tolerance was assessed using the Quality of Alimentation questionnaire. Primary outcome measure was food tolerance and %EWL. RESULTS Food tolerance was significantly better in the antral sparing group compared to the antral resection group after 3 and 6 months. The two groups were comparable in %EWL and BMI change after 3 and 6 months. Six months after surgery, the majority of patients had a very good quality of life, with no significant difference between the two groups (p = 0.877). There was no significant difference between the two groups in operative time, intraoperative blood loss, and hospital stay. CONCLUSIONS Preservation of the pyloric antrum during LSG is associated with significantly better food tolerance and comparable effect of weight loss up to 6 months postoperatively when compared with total antral resection.
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Affiliation(s)
- Ibrahim G Khalifa
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 11562, Egypt
| | - Wael L Tobar
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 11562, Egypt
| | - Tarek O Hegazy
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 11562, Egypt
| | - Hany A Balamoun
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 11562, Egypt.
| | - Sameh Mikhail
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 11562, Egypt
| | | | - Elsayed A Elsayed
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 11562, Egypt
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16
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Suganuma Y, Shimizu T, Sato T, Morii T, Fujita H, Harada Sassa M, Yamada Y. Magnitude of slowing gastric emptying by glucagon-like peptide-1 receptor agonists determines the amelioration of postprandial glucose excursion in Japanese patients with type 2 diabetes. J Diabetes Investig 2020; 11:389-399. [PMID: 31301103 PMCID: PMC7078094 DOI: 10.1111/jdi.13115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/08/2019] [Accepted: 07/07/2019] [Indexed: 12/25/2022] Open
Abstract
AIMS/INTRODUCTION Pharmacological levels of glucagon-like peptide-1 (GLP-1) can decelerate gastric emptying (GE) and reduce postprandial glucose levels. Most previous studies have used liquid meals to evaluate GE. We evaluated the effects of GLP-1 receptor agonists (GLP-1 RAs) on GE and postprandial glucose excursion in Japanese type 2 diabetes mellitus patients using a combination of solid and liquid meals. MATERIALS AND METHODS In this single-center, prospective, open-label study, nine healthy individuals and 17 patients with type 2 diabetes mellitus consumed a 460-kcal combination of a solid and liquid meal labeled with 13 C-acetic acid. GE was measured from t = 0 to 150 min in a continuous 13 C breath test. Eight participants with type 2 diabetes mellitus were administered GLP-1 RAs, and we examined the relationship between GE and blood glucose excursion. RESULTS There were no differences in the average GE coefficient (GEC) and lag time between the healthy and type 2 diabetes mellitus groups. However, the type 2 diabetes mellitus group showed larger GEC variations (P < 0.05). The coefficient of variation of R-R intervals was a significant predictor of GEC in type 2 diabetes mellitus patients (P < 0.01). The short-acting GLP-1 RA reduced the GEC at 1 month (P = 0.012), whereas the long-acting GLP-1 RA did not significantly change the GEC after treatment. A positive relationship was observed between postprandial glucose excursion from T0 min to T60 min and the GEC (r2 = 0.75; P < 0.01). CONCLUSIONS The reduction in GE rate by the administration of GLP-1 RAs can predict the improvement in postprandial glucose excursion in type 2 diabetes mellitus patients.
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Affiliation(s)
- Yumi Suganuma
- Department of Endocrinology, Diabetes and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Tatsunori Shimizu
- Department of Endocrinology, Diabetes and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Takehiro Sato
- Department of Endocrinology, Diabetes and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Tsukasa Morii
- Department of Endocrinology, Diabetes and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Hiroki Fujita
- Department of Endocrinology, Diabetes and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Mariko Harada Sassa
- Institute for Advancement of Clinical and Translational ScienceKyoto University HospitalKyotoJapan
| | - Yuichiro Yamada
- Department of Endocrinology, Diabetes and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
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17
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Li C, Yu W, Wu P, Chen XD. Current in vitro digestion systems for understanding food digestion in human upper gastrointestinal tract. Trends Food Sci Technol 2020. [DOI: 10.1016/j.tifs.2019.12.015] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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18
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PECULIARITIES OF STATE OF PROTECTION AND AGGRESSION FACTORS IN PATIENTS WITH DIABETES MELLITUS TYPE II AND GASTROESOPHAGEAL REFLUX DISEASE. EUREKA: HEALTH SCIENCES 2020. [DOI: 10.21303/2504-5679.2020.001080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Diabetes mellitus is one of the most serious problems of the clinical medicine. This is determined by the fact that it is followed by multisystemic affects, as well as complications on the side of other organs and systems, among which a special place is occupied by gastroesophageal reflux disease. As for the combination and mutual influence of diabetes mellitus and gastroesophageal reflux disease, this issue has not been studied yet, the data of modern literature are not complete and quite contradictory.
The aim of the study: to investigate the state of the factors of aggression and protection of the oesophageal mucosa in patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease without associated pathology.
Method. There were two groups of patients under observation. The first group included 45 patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease (26 men and 19 women). The second group included 38 patients with gastroesophageal reflux disease without associated pathology – 20 men and 18 women. By sex, age, body weight, Helicobacter pylori infection, smoking and alcohol consumption, both groups were comparable. The surveillance program included determining the compensation ratio of carbohydrate metabolism and the state of the factor. The antioxidant protection factor was assessed by the level of catalase activity in the blood serum, as well as by the diameter of the celiac trunk and the blood flow velocity in it. Statistical processing of the obtained data was carried out with the aid of the program WINDOWS STATISTIKA 6.0. For all types of analysis, differences were considered statistically significant with p<0.05.
Results. During the study, we found that in patients with diabetes mellitus type II with concomitant gastroesophageal reflux disease, as well as in patients with gastroesophageal reflux disease without associated pathology, the level of pH-metry was reduced, but with varying measures of confidence. At the same time, we found that patients with GERD without associated pathology had a decrease in the blood flow velocity in the celiac trunk. Concurrently, we ascertained that the decrease in the blood flow velocity in patients of both groups reduced the diameter of the celiac trunk.
Conclusions. In patients with diabetes mellitus type II, concomitant gastroesophageal reflux disease has a subtle clinical presentation that is affected by a significant decline in mucosal sealing protection factors. In patients with GERD without associated pathology, typical clinical manifestations, accompanied by inflammation, acid regurgitation and dyspepsia, are more vivid.
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Alterations of Gastric Emptying Features Following Laparoscopic Sleeve Gastrectomy in Chinese Patients with Obesity: a Self-Controlled Observational Study. Obes Surg 2019; 29:617-625. [PMID: 30536019 DOI: 10.1007/s11695-018-3571-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular metabolic surgical procedure. Alteration in motor gastric function is a fundamental feature following LSG but still remains controversial. PURPOSE To determine the gastric emptying time 3 month after LSG, correlations between gastric emptying time and body weight, weight loss, and glycemia levels, alongside determining predictive factors of weight loss at the 3-month follow-up. MATERIALS AND METHODS Twenty-one patients were recruited in this study. Gastric emptying time was measured using a standard solid-phase gastric emptying scan at both baseline and 3 months after LSG. Paired sample t tests and a general linear model with repeated measures were applied to investigate the alterations in major parameters after surgery. Univariate analyses were performed to evaluate the factors predicting weight loss at the 3-month follow-up. RESULTS Compared with baseline levels, gastric emptying time, body weight, and HbA1c levels decreased significantly at 3 months after LSG (P < 0.001). Significant positive correlations were detected between HbA1c levels and gastric emptying time at baseline (P = 0.03). Significant positive correlations were detected between HbA1c levels at baseline and change in gastric emptying time (P = 0.03). Univariate logistic regression revealed a lower baseline BMI level to be independently associated with %EWL (P < 0.001). CONCLUSIONS The rate of gastric emptying increased following LSG. Patients with a higher risk of type 2 diabetes at baseline had longer gastric emptying times prior to treatment and significantly shortened emptying times following surgery.
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20
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Abstract
PURPOSE OF REVIEW This review provides important updates in systemic sclerosis (SSc)-related gastrointestinal disease, with a particular focus on the diagnosis and management of dysmotility. RECENT FINDINGS In the past 2 years, several studies were published that present interesting diagnostic insights into SSc and gastrointestinal dysmotility. Studies focusing on new therapies and the novel application of existing therapies, both in SSc and non-SSc-associated gastrointestinal dysmotility syndromes, demonstrate progress in the management of these challenging complications. SUMMARY SSc gastrointestinal disease is heterogeneous in its clinical presentation, which presents a challenge in diagnosis and management. Objective studies may help to identify patterns of gastrointestinal dysmotility and more specifically target therapy. A variety of drugs are now available or are under study in the management of gastrointestinal dysmotility, such as prucalopride, intravenous immunoglobulin, pyridostigmine, linaclotide, relamorelin, and others. These drugs may improve symptoms and quality of life in SSc gastrointestinal patients. Combination therapies are also under study. Electroacupuncture, dietary intervention (e.g. medical nutrition therapy, low FODmap diet), and medical cannibus may also play a role in alleviating patient symptoms; however, more data are needed to define the role of these interventions in SSc.
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Obici L, Suhr OB. Diagnosis and treatment of gastrointestinal dysfunction in hereditary TTR amyloidosis. Clin Auton Res 2019; 29:55-63. [PMID: 31452022 PMCID: PMC6763516 DOI: 10.1007/s10286-019-00628-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE To review the management of gastrointestinal symptoms in patients with hereditary transthyretin amyloidosis, discussing diagnostic evaluations, assessment of disease progression and therapeutic strategies that could be implemented in routine practice. METHODS Literature review. Key search terms included "gastrointestinal symptoms", "autonomic neuropathy", "hereditary transthyretin amyloidosis" and "familial amyloid polyneuropathy". RESULTS Gastrointestinal disturbances are a common and serious manifestation of hereditary transthyretin amyloidosis, with significant effects on patients' quality of life and demonstrating a strong association with mortality. Gastrointestinal involvement is more often subclinical in the early stages of the disease, although in some patients gastric and/or bowel abnormalities may be the inaugural symptoms. In both cases, under-recognition, delayed investigation and suboptimal treatment frequently occur. A clear understanding of the mechanisms underlying gastrointestinal dysfunction in hereditary transthyretin amyloidosis is still lacking, but similar to diabetic enteropathy, multiple pathophysiological alterations seem to play a role. CONCLUSIONS Early detection and treatment of gastrointestinal disturbances is key to the successful treatment of this devastating disease. Gastroenterologists play a valuable role in both the diagnosis and the timely management of gastrointestinal symptoms in hereditary transthyretin amyloidosis and should, therefore, be part of a multidisciplinary and comprehensive approach to this disorder.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
| | - Ole B Suhr
- Department of Medicine, Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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22
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Postprandial Glucose Control in Type 1 Diabetes: Importance of the Gastric Emptying Rate. Nutrients 2019; 11:nu11071559. [PMID: 31295897 PMCID: PMC6683017 DOI: 10.3390/nu11071559] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 12/14/2022] Open
Abstract
The achievement of optimal post-prandial (PP) glucose control in patients with type 1 diabetes (T1DM) remains a great challenge. This review summarizes the main factors contributing to PP glucose response and discusses the likely reasons why PP glucose control is rarely achieved in T1DM patients. The macronutrient composition of the meal, the rate of gastric emptying and premeal insulin administration are key factors affecting the PP glucose response in T1DM. Although the use of continuous insulin infusion systems has improved PP glucose control compared to conventional insulin therapy, there is still need for further ameliorations. T1DM patients frequently present a delayed gastric emptying (GE) that produces a lower but more prolonged PP hyperglycemia. In addition, delayed GE is associated with a longer time to reach the glycemic peak, with a consequent mismatch between PP glucose elevation and the timing of premeal insulin action. On this basis, including GE time and meal composition in the algorithms for insulin bolus calculation of the insulin delivery systems could be an important step forward for optimization of PP glucose control in T1DM.
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Outcomes and Future Directions of Per-Oral Endoscopic Pyloromyotomy: A View from France. Gastrointest Endosc Clin N Am 2019; 29:139-149. [PMID: 30396523 DOI: 10.1016/j.giec.2018.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroparesis is a challenging functional gastroenterological disorder, the complex pathophysiology of which hampers development of therapeutic modalities. Per-oral pyloromyotomy (POP) is a promising endoscopic therapy with a short-term clinical success rate of greater than 80%. Interest in POP is increasing, particularly in France, a country in which there is considerable expertise in submucosal endoscopy and functional disorders. Long-term follow-up and pyloric function evaluation are needed to assess the efficacy of POP in gastroparetic patients.
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24
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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Angeli TR, O'Grady G. Challenges in defining, diagnosing, and treating diabetic gastroparesis. J Diabetes Complications 2018; 32:127-128. [PMID: 29198995 DOI: 10.1016/j.jdiacomp.2017.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 11/12/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Timothy R Angeli
- Auckland Bioengineering Institute, University of Auckland, New Zealand.
| | - Gregory O'Grady
- Auckland Bioengineering Institute, University of Auckland, New Zealand; Department of Surgery, University of Auckland, New Zealand
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26
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Mihai BM, Mihai C, Cijevschi-Prelipcean C, Grigorescu ED, Dranga M, Drug V, Sporea I, Lăcătușu CM. Bidirectional Relationship between Gastric Emptying and Plasma Glucose Control in Normoglycemic Individuals and Diabetic Patients. J Diabetes Res 2018; 2018:1736959. [PMID: 30402500 PMCID: PMC6192082 DOI: 10.1155/2018/1736959] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 05/14/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022] Open
Abstract
Gastric emptying and glycemic control pathways are closely interrelated processes. Gastric chyme is transferred into the duodenum with velocities depending on its solid or liquid state, as well as on its caloric and nutritional composition. Once nutrients enter the intestine, the secretion of incretins (hormonal products of intestinal cells) is stimulated. Among incretins, glucagon-like peptide-1 (GLP-1) has multiple glycemic-regulatory effects that include delayed gastric emptying, thus triggering a feedback loop lowering postprandial serum glucose levels. Glycemic values also influence gastric emptying; hyperglycemia slows it down, and hypoglycemia accelerates it, both limiting glycemic fluctuations. Disordered gastric emptying in diabetes mellitus is understood today as a complex pathophysiological condition, with both irreversible and reversible components and high intra- and interindividual variability of time span and clinical features. While limited delays may be useful for reducing postprandial hyperglycemias, severely hindered gastric emptying may be associated with higher glycemic variability and worsened long-term glycemic control. Therapeutic approaches for both gastric emptying and glycemic control include dietary modifications of meal structure or content and drugs acting as GLP-1 receptor agonists. In the foreseeable future, we will probably witness a wider range of dietary interventions and more incretin-based medications used for restoring both gastric emptying and glycemic levels to nearly physiological levels.
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Affiliation(s)
- Bogdan Mircea Mihai
- “Grigore T. Popa” University of Medicine and Pharmacy, Clinical Centre of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” Clinical Hospital, Iași, Romania
| | - Cătălina Mihai
- “Grigore T. Popa” University of Medicine and Pharmacy, Institute of Gastroenterology and Hepatology, “Sf. Spiridon” Clinical Hospital, Iași, Romania
| | - Cristina Cijevschi-Prelipcean
- “Grigore T. Popa” University of Medicine and Pharmacy, Institute of Gastroenterology and Hepatology, “Sf. Spiridon” Clinical Hospital, Iași, Romania
| | - Elena-Daniela Grigorescu
- “Grigore T. Popa” University of Medicine and Pharmacy, Clinical Centre of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” Clinical Hospital, Iași, Romania
| | - Mihaela Dranga
- “Grigore T. Popa” University of Medicine and Pharmacy, Institute of Gastroenterology and Hepatology, “Sf. Spiridon” Clinical Hospital, Iași, Romania
| | - Vasile Drug
- “Grigore T. Popa” University of Medicine and Pharmacy, Institute of Gastroenterology and Hepatology, “Sf. Spiridon” Clinical Hospital, Iași, Romania
| | - Ioan Sporea
- Gastroenterology, “Victor Babes” University of Medicine and Pharmacy Timișoara, Romania
| | - Cristina Mihaela Lăcătușu
- “Grigore T. Popa” University of Medicine and Pharmacy, Clinical Centre of Diabetes, Nutrition and Metabolic Diseases, “Sf. Spiridon” Clinical Hospital, Iași, Romania
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Wixner J, Suhr OB, Anan I. Management of gastrointestinal complications in hereditary transthyretin amyloidosis: a single-center experience over 40 years. Expert Rev Gastroenterol Hepatol 2018; 12:73-81. [PMID: 29073801 DOI: 10.1080/17474124.2018.1397511] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hereditary transthyretin amyloidosis (ATTRm amyloidosis) is a rare disease caused by the deposition and accumulation of insoluble non-native transthyretin fibrils in the body. The disease inevitably results in widespread organ disruption, and poor life expectancy. The GI tract is one organ system vulnerable to disruption and, although the clinical presentation of the disease varies, GI involvement affects most patients with ATTRm amyloidosis. Areas covered: This article presents our experience with diagnosing and treating the GI symptoms of ATTRm amyloidosis patients at our center over the last 40 years, in the Swedish clustering area of the disease. Our aim is to help other physicians to better manage GI complications in patients with this rare but widespread condition. Expert commentary: GI symptoms are debilitating complications for ATTRm amyloidosis patients to experience, yet with the appropriate questioning and diagnosis methods, symptomatic treatments of these symptoms can be implemented to provide relief. Further, patients with fewer GI complications and a good nutritional status are also better candidates for liver transplantation which, in selected cases, is the best disease-modifying treatment of ATTRm amyloidosis to date.
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Affiliation(s)
- Jonas Wixner
- a Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Ole B Suhr
- a Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Intissar Anan
- a Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
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Chen TY, Ferruzzi MG, Wu QL, Simon JE, Talcott ST, Wang J, Ho L, Todd G, Cooper B, Pasinetti GM, Janle EM. Influence of diabetes on plasma pharmacokinetics and brain bioavailability of grape polyphenols and their phase II metabolites in the Zucker diabetic fatty rat. Mol Nutr Food Res 2017; 61. [PMID: 28568316 DOI: 10.1002/mnfr.201700111] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/05/2017] [Accepted: 05/22/2017] [Indexed: 12/17/2022]
Abstract
SCOPE The effect of diabetes on the pharmacokinetics, bioavailability and brain distribution of grape polyphenols and select metabolites was studied in the Zucker diabetic fatty (ZDF) rat model. METHODS AND RESULTS (ZDF) rats and their lean controls (LN) were dosed with a Standardized Grape Polyphenol (SGP) Mixture consisting of grape seed extract, Concord grape juice and resveratrol (RES) by oral gavage for 10 days. An 8-h pharmacokinetic study was performed. After 24 h, a second dose of SGP was administered and 1 h later animals were sacrificed and brain tissue was harvested. Plasma, urine, and brain tissue were analyzed for grape polyphenols. ZDF rats exhibited significantly diminished Cmax for all catechin, epicatechin, quercetin and resveratrol conjugated metabolites. Bioavailability was significantly lower in ZDF rats for methylated flavan-3-ol, RES, and quercetin metabolites. Significantly lower levels of metabolites of RES, quercetin, and flavan-3-ols were found in brains of ZDF rats. There was no significant difference between ZDF and LN in anthocyanins in plasma and no anthocyanins were detectable in brain extracts. ZDF rats showed significantly higher urinary excretion for all polyphenols. CONCLUSION Diabetes may alter the overall bioavailability of some polyphenols in plasma and brain in part due to higher urinary clearance.
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Affiliation(s)
- Tzu-Ying Chen
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Mario G Ferruzzi
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA.,Department of Food Science, Purdue University, West Lafayette, Indiana, USA
| | - Qing-Li Wu
- Department of Plant Biology, Rutgers University, New Brunswick, New Jersey, USA
| | - James E Simon
- Department of Plant Biology, Rutgers University, New Brunswick, New Jersey, USA
| | - Stephen T Talcott
- Department of Food Science, Texas A&M University, College Station, Texas, USA
| | - Jun Wang
- Department of Neurology, Mount Sinai School of Medicine, New York, New York, USA
| | - Lap Ho
- Department of Psychiatry, Mount Sinai School of Medicine, New York, New York, USA
| | - George Todd
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Bruce Cooper
- Bindley Bioscience Center, Purdue University, West Lafayette, Indiana, USA
| | - Giulio M Pasinetti
- Department of Psychiatry, Mount Sinai School of Medicine, New York, New York, USA
| | - Elsa M Janle
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
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29
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Sanger GJ, Pasricha PJ. Investigational drug therapies for the treatment of gastroparesis. Expert Opin Investig Drugs 2017; 26:331-342. [PMID: 28127997 DOI: 10.1080/13543784.2017.1288214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Gastroparesis is defined by nausea, vomiting, pain, early satiety and bloating, and characterized by delayed gastric emptying without obvious structural abnormalities. Metoclopramide is widely used, increasing gastric emptying and inhibiting nausea and vomiting. Other drugs are available in certain countries and some are used 'off-label' because they increase gastric emptying or inhibit emesis. However, correlation between gastroparesis symptoms and rates of gastric emptying is poor. For anti-emetic drugs, dose-ranging and Phase III trials in gastroparesis are lacking. Areas covered: Gastric motility may still be disordered, leading to nausea, even though gastric emptying is unchanged. One hypothesis is that interstitial cells of Cajal (ICC) are damaged by diabetes leading to gastric dysrhythmia and nausea. Novel approaches to treatment of nausea also include the use of ghrelin receptor agonists, highlighting a link between appetite and nausea. Expert opinion: There is an urgent need to diversify away from historical drug targets. In particular, there is a need to control nausea by regulating ICC functions and/or by facilitating appetite via ghrelin receptor agonists. It is also important to note that different upper gastrointestinal disorders (gastroparesis, chronic unexplained nausea and vomiting, functional dyspepsia) are difficult to distinguish apart, suggesting wider therapeutic opportunity.
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Affiliation(s)
- Gareth J Sanger
- a Professor of Neuropharmacology , Blizard Institute and the National Centre for Bowel Research, Barts The London School of Medicine and Dentistry, Queen Mary University of London , London , UK
| | - Pankaj Jay Pasricha
- b Vice Chair of Medicine for Innovation and Commercialization , Johns Hopkins University School of Medicine, Director, Johns Hopkins Center for Neurogastroenterology, Professor of Medicine and Neurosciences, Professor of Innovation Management, Johns Hopkins Carey School of Business , Baltimore , MD , USA
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30
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Duvoisin G, Krishnan U. Gastric Function in Children with Oesophageal Atresia and Tracheoesophageal Fistula. Front Pediatr 2017; 5:76. [PMID: 28447027 PMCID: PMC5388682 DOI: 10.3389/fped.2017.00076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/29/2017] [Indexed: 01/14/2023] Open
Abstract
Oesophageal atresia and tracheoesophageal fistula (OA-TOF) are a multifaceted condition which affects patients throughout their lives. Even though it is one of the most common gastrointestinal malformations, most of the current studies focus on gastro-oesophageal reflux disease, anastomotic strictures, and feeding difficulties. However, there is increasing evidence that a proportion of patients with OA-TOF also have abnormal gastric function. This review aims to provide a comprehensive understanding of studies of gastric function in patients with OA-TOF. The etiology of this abnormality has been hypothesized to be congenital and/or acquired. Several modalities are currently available for the investigation of gastric function, each of them trying to answer specific clinical questions. This review summarizes the studies that have looked at gastric function in the OA-TOF cohort with gastric emptying studies (gastric emptying scintigraphy and 13C octanoic breath test), gastric manometry, electrogastrography, and oral glucose tolerance test. However, these modalities are limited due to poor age-specific normative values and heterogeneous methodologies used. The evaluation of symptoms in this cohort is crucial, modalities for abnormal gastric function are also described. With appropriate investigations and symptoms questionnaires, treatment strategies can be implemented to correct abnormal gastric function and thereby improve the outcomes and quality of life of patients with OA-TOF. This review highlights the need for large international multicentre collaborative studies and high-quality prospective randomized controlled trials to improve our understanding of gastric function in this cohort.
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Affiliation(s)
- Gilles Duvoisin
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, NSW, Australia.,Department of Paediatrics, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
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31
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Steinert RE, Feinle-Bisset C, Asarian L, Horowitz M, Beglinger C, Geary N. Ghrelin, CCK, GLP-1, and PYY(3-36): Secretory Controls and Physiological Roles in Eating and Glycemia in Health, Obesity, and After RYGB. Physiol Rev 2017; 97:411-463. [PMID: 28003328 PMCID: PMC6151490 DOI: 10.1152/physrev.00031.2014] [Citation(s) in RCA: 358] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The efficacy of Roux-en-Y gastric-bypass (RYGB) and other bariatric surgeries in the management of obesity and type 2 diabetes mellitus and novel developments in gastrointestinal (GI) endocrinology have renewed interest in the roles of GI hormones in the control of eating, meal-related glycemia, and obesity. Here we review the nutrient-sensing mechanisms that control the secretion of four of these hormones, ghrelin, cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1), and peptide tyrosine tyrosine [PYY(3-36)], and their contributions to the controls of GI motor function, food intake, and meal-related increases in glycemia in healthy-weight and obese persons, as well as in RYGB patients. Their physiological roles as classical endocrine and as locally acting signals are discussed. Gastric emptying, the detection of specific digestive products by small intestinal enteroendocrine cells, and synergistic interactions among different GI loci all contribute to the secretion of ghrelin, CCK, GLP-1, and PYY(3-36). While CCK has been fully established as an endogenous endocrine control of eating in healthy-weight persons, the roles of all four hormones in eating in obese persons and following RYGB are uncertain. Similarly, only GLP-1 clearly contributes to the endocrine control of meal-related glycemia. It is likely that local signaling is involved in these hormones' actions, but methods to determine the physiological status of local signaling effects are lacking. Further research and fresh approaches are required to better understand ghrelin, CCK, GLP-1, and PYY(3-36) physiology; their roles in obesity and bariatric surgery; and their therapeutic potentials.
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Affiliation(s)
- Robert E Steinert
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Christine Feinle-Bisset
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Lori Asarian
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Michael Horowitz
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Christoph Beglinger
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Nori Geary
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
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Ravages of Diabetes on Gastrointestinal Sensory-Motor Function: Implications for Pathophysiology and Treatment. Curr Gastroenterol Rep 2016; 18:6. [PMID: 26768896 DOI: 10.1007/s11894-015-0481-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Symptoms related to functional and sensory abnormalities are frequently encountered in patients with diabetes mellitus. Most symptoms are associated with impaired gastric and intestinal function. In this review, we discuss basic concepts of sensory-motor dysfunction and how they relate to clinical findings and gastrointestinal abnormalities that are commonly seen in diabetes. In addition, we review techniques that are available for investigating the autonomic nervous system, neuroimaging and neurophysiology of sensory-motor function. Such technological advances, while not readily available in the clinical setting, may facilitate stratification and individualization of therapy in diabetic patients in the future. Unraveling the structural, mechanical, and sensory remodeling in diabetes disease is based on a multidisciplinary approach that can bridge the knowledge from a variety of scientific disciplines. The final goal is to increase the understanding of the damage to GI structures and to sensory processing of symptoms, in order to assist clinicians with developing an optimal mechanics based treatment.
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Gallego D, Ortega O, Arenas C, López I, Mans E, Clavé P. The effect of levosulpiride on in vitro motor patterns in the human gastric fundus, antrum, and jejunum. Neurogastroenterol Motil 2016; 28:879-90. [PMID: 26842870 DOI: 10.1111/nmo.12788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 01/06/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Levosulpiride is a 5HT4 agonist/D2 antagonist prokinetic agent used to improve gastric emptying in patients with functional dyspepsia or gastroparesis. The aim of this study was to characterize its effect on the main in vitro motility patterns in the human fundus, antrum, and jejunum. METHODS Circular muscle strips from human stomach (antrum and fundus) and jejunum, obtained from 46 patients undergoing bariatric surgery, were studied using organ baths. Enteric motor neurons (EMNs) were stimulated by electrical field stimulation (EFS). KEY RESULTS Levosulpiride, caused an increase in the EFS-induced cholinergic contractions in the gastric antrum (+37 ± 15.18% at 100 μM, pEC50 = 4.46 ± 0.14; p < 0.05, n = 8) and jejunum (+45.4 ± 22.03% at 100 μM, pEC50 = 3.78 ± 6.81; p < 0.05, n = 5), but not in the gastric fundus. It also caused a slight decrease in tone and frequency of spontaneous contractions in the jejunum, but did not have any major effect on tone or spontaneous contractions in the stomach. It did not have any effect on EFS-induced relaxations mediated by nitric oxide (NO) in the stomach (antrum and fundus) and by NO and ATP in the jejunum. CONCLUSIONS & INFERENCES Our results suggest that the prokinetic effects of levosulpiride in humans are mainly due to the facilitation of the release of acetylcholine by enteric motor neurons in the gastric antrum and the jejunum.
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Affiliation(s)
- D Gallego
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - O Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C Arenas
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - I López
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain
| | - E Mans
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - P Clavé
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas CIBERehd, Instituto de Salud Carlos III, Barcelona, Spain.,Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró, Universitat Autònoma de Barcelona, Barcelona, Spain.,Health Sciences Research Institute of the Germans Trias i Pujol Foundation, Barcelona, Spain
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Sangnes DA, Søfteland E, Biermann M, Gilja OH, Thordarson H, Dimcevski G. [Gastroparesis - causes, diagnosis and treatment]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:822-6. [PMID: 27221182 DOI: 10.4045/tidsskr.15.0503] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Gastroparesis is a motility disorder of the stomach. The symptoms are non-specific: nausea and vomiting are most common. Stomach pains, early satiety, postprandial fullness and bloating are also frequent symptoms. Current diagnostic criteria require delayed gastric emptying in the absence of any detectable mechanical obstruction. In this review article we elucidate the causes, assessment and treatment options.MATERIAL AND METHOD Structured article search in Embase and PubMed.RESULTS A number of conditions can lead to gastroparesis. The most frequent somatic cause is diabetes mellitus. Gastroparesis may also be iatrogenically inflicted by means of surgery or drugs. It may be difficult to discriminate between functional dyspepsia and idiopathic gastroparesis. Examination is based on patient history, gastroscopy and measurement of the rate of gastric emptying. Biochemical tests are also relevant for differential diagnosis. The treatment is primarily symptomatic, and consists of dietary measures, fluid therapy, drugs, gastric electrical stimulation, or endoscopic or surgical intervention in the form of insertion of a feeding tube for nutrition and abdominal relief, pyloroplasty or gastrectomy.INTERPRETATION Gastroparesis is a serious motility disorder. The condition may have significant consequences for patients, entailing reduced quality of life, reduced workforce participation and a considerable need for health assistance.
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Affiliation(s)
- Dag A Sangnes
- Gastroenterologisk seksjon Medisinsk avdeling Haukeland universitetssykehus
| | - Eirik Søfteland
- Endokrinologisk seksjon Medisinsk avdeling Haukeland universitetssykehus
| | - Martin Biermann
- Senter for nukleærmedisin og PET Radiologisk avdeling Haukeland universitetssykehus og Klinisk institutt 1 Universitetet i Bergen
| | - Odd Helge Gilja
- Nasjonalt senter for gastroenterologisk ultrasonografi Haukeland universitetssykehus og Klinisk institutt 1 Universitetet i Bergen
| | | | - Georg Dimcevski
- Gastroenterologisk seksjon Medisinsk avdeling Haukeland universitetssykehus og Klinisk institutt 1 Universitetet i Bergen
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36
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Cho JW, Lee HW, Hwang S. Benefit of pyloroplasty to prevent gastric stasis in intrahepatic cholangiocarcinoma patients undergoing extensive left-sided lymph node dissection. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:32-7. [PMID: 26925148 PMCID: PMC4767264 DOI: 10.14701/kjhbps.2016.20.1.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 12/22/2015] [Accepted: 12/30/2015] [Indexed: 11/22/2022]
Abstract
Backgrounds/Aims Intrahepatic cholangiocacinoma (IHCC) can result in spread of tumor cells to the lymph nodes (LNs) around the gastric lesser curvature. Extensive dissection of the gastric lesser curvature can induce injury to the extragastric vagus nerve branches that control motility of the pyloric sphincter and result in intractable gastric stasis. Herein, we presented our experience of preventive pyloroplasty added to resection of IHCC to address dissection-induced gastric stasis in 6 patients during 15-years. Methods We analyzed the survival outcomes of 54 IHCC patients presenting left-sided LN metastasis. Nine study patients who underwent extended left-sided LN dissection including lesser curvature LN dissection were selected and divided into 2 groups according to performance of preventive pyloroplasty and the incidence of gastric stasis was analyzed. Results All 54 patients were classified as stage IV due to T1-3N1M0 stage. The tumor recurrence rate were 56.4% at 1 year, 84.3% at 3 years and 84.3% at 5 years; and the overall patient survival rate were 51.9% at 1 year, 13.6% at 3 years and 6.8% at 5 years. In all 3 study patients who did not receive pyloroplasty, overt postoperative gastric stasis persisted for >10 days leading to prolonged hospital stay. In contrast, none of the 6 study patients who underwent pyloroplasty suffered from gastric stasis. Conclusions Pyloroplasty is a useful surgical option to prevent gastric stasis when extensive left-sided LN dissection is required in IHCC patients with LN metastasis who have very poor post-resection prognosis.
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Affiliation(s)
- Jae-Won Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hae-Won Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Zhao X, Mashimo H. Current and Emerging Medical Therapies for Gastroparesis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2015; 13:452-72. [PMID: 26507073 DOI: 10.1007/s11938-015-0071-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OPINION STATEMENT Gastroparesis likely involves various pathophysiological disorders and is increasingly prevalent as complications of surgeries, medications, and chronic diabetes. Key to diagnosis is evidence of delayed gastric emptying, generally based on standardized scintigraphy, and ruling out distal obstruction or other dysmotilities. Initial medical management includes reviewing potentially exacerbating medications and ruling out other reversible causes, achieving tighter glucose control in diabetics, and implementing dietary and lifestyle changes. While current available medications are limited, symptomatic control is aimed at improving gastric emptying, alleviating nausea and vomiting, and treating associated abdominal pain. Other potential therapies are aimed at reducing acid production, improving gastric accommodation or pyloric dysfunction, and treating bacterial overgrowth. Future studies should be aimed toward identification of subpopulations of gastroparetics who are better responders to the various medications based on differences in underlying pathophysiology and adopting standardized study end point measures that may allow for comparisons across trials. This chapter will review current treatment options, upcoming promising medications, and some of the hurdles in advancing the field forward.
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Affiliation(s)
- Xiaofeng Zhao
- Center for Swallowing and Motility Disorders, VA Boston Healthcare/Harvard Medical School, 1400 VFW Pkwy, West Roxbury, MA, 02132, USA
| | - Hiroshi Mashimo
- Center for Swallowing and Motility Disorders, VA Boston Healthcare/Harvard Medical School, 1400 VFW Pkwy, West Roxbury, MA, 02132, USA.
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Kellow NJ, Coughlan MT. Effect of diet-derived advanced glycation end products on inflammation. Nutr Rev 2015; 73:737-59. [PMID: 26377870 DOI: 10.1093/nutrit/nuv030] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Advanced glycation end products (AGEs) formed via the Maillard reaction during the thermal processing of food contributes to the flavor, color, and aroma of food. A proportion of food-derived AGEs and their precursors is intestinally absorbed and accumulates within cells and tissues. AGEs have been implicated in the pathogenesis of diabetes-related complications and several chronic diseases via interaction with the receptor for AGEs, which promotes the transcription of genes that control inflammation. The dicarbonyls, highly reactive intermediates of AGE formation, are also generated during food processing and may incite inflammatory responses through 1) the suppression of protective pathways, 2) the incretin axis, 3) the modulation of immune-mediated signaling, and 4) changes in gut microbiota profile and metabolite sensors. In animal models, restriction of dietary AGEs attenuates chronic low-grade inflammation, but current evidence from human studies is less clear. Here, the emerging relationship between excess dietary AGE consumption and inflammation is explored, the utility of dietary AGE restriction as a therapeutic strategy for the attenuation of chronic diseases is discussed, and possible avenues for future investigation are suggested.
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Affiliation(s)
- Nicole J Kellow
- N.J. Kellow and M.T. Coughlan are with the Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia, and the Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Medical Research and Education Precinct, Melbourne, Victoria, Australia. M.T. Coughlan is with the Department of Medicine, Central Clinical School, Monash University, Alfred Medical Research and Education Precinct, Melbourne, Victoria, Australia
| | - Melinda T Coughlan
- N.J. Kellow and M.T. Coughlan are with the Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia, and the Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Medical Research and Education Precinct, Melbourne, Victoria, Australia. M.T. Coughlan is with the Department of Medicine, Central Clinical School, Monash University, Alfred Medical Research and Education Precinct, Melbourne, Victoria, Australia.
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Abstract
Aging is characterized by a diminished homeostatic regulation of physiologic functions, including slowing of gastric emptying. Gastric and small intestinal motor and humoral mechanisms in humans are complex and highly variable: ingested food is stored, mixed with digestive enzymes, ground into small particles, and delivered as a liquefied form into the duodenum at a rate allowing efficient digestion and absorption. In healthy aging, motor function is well preserved whereas deficits in sensory function are more apparent. The effects of aging on gastric emptying are relevant to the absorption of oral medications and the regulation of appetite, postprandial glycemia, and blood pressure.
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Affiliation(s)
- Stijn Soenen
- Discipline of Medicine, National Health and Medical Research Council of Australia (NHMRC) Centre of Research Excellence in Translating Nutritional Science to Good Health, Royal Adelaide Hospital, The University of Adelaide, Frome Road, Adelaide, South Australia 5000, Australia.
| | - Chris K Rayner
- Discipline of Medicine, National Health and Medical Research Council of Australia (NHMRC) Centre of Research Excellence in Translating Nutritional Science to Good Health, Royal Adelaide Hospital, The University of Adelaide, Frome Road, Adelaide, South Australia 5000, Australia
| | - Michael Horowitz
- Discipline of Medicine, National Health and Medical Research Council of Australia (NHMRC) Centre of Research Excellence in Translating Nutritional Science to Good Health, Royal Adelaide Hospital, The University of Adelaide, Frome Road, Adelaide, South Australia 5000, Australia
| | - Karen L Jones
- Discipline of Medicine, National Health and Medical Research Council of Australia (NHMRC) Centre of Research Excellence in Translating Nutritional Science to Good Health, Royal Adelaide Hospital, The University of Adelaide, Frome Road, Adelaide, South Australia 5000, Australia
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McCarty TR, Rustagi T. Endoscopic treatment of gastroparesis. World J Gastroenterol 2015; 21:6842-6849. [PMID: 26078560 PMCID: PMC4462724 DOI: 10.3748/wjg.v21.i22.6842] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/05/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis has traditionally been a largely medically managed disease with refractory symptoms typically falling under the umbrella of the surgical domain. Surgical options include, but are not limited to, gastrostomy, jejunostomy, pyloromyotomy, or pyloroplasty, and the Food and Drug Administration approved gastric electrical stimulation implantation. Endoscopic management of gastroparesis most commonly involves intrapyloric botulinum toxin injection; however, there exists a variety of endoscopic approaches on the horizon that have the potential to radically shift standard of care. Endoscopic management of gastroparesis seeks to treat delayed gastric emptying with a less invasive approach compared to the surgical approach. This review will serve to highlight such innovative and potentially transformative, endoscopic interventions available to gastroenterologists in the management of gastroparesis.
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Abstract
PURPOSE OF REVIEW Gastroparesis is a disorder with delayed gastric emptying in the absence of mechanical obstruction. It is one of the more common dysmotilities that occur in the gastrointestinal tract, and is thought to primarily affect adults. Pediatric cases of gastroparesis were considered rare; however, recent evidence suggests growing recognition in children and adolescents. Therefore, it is important for the pediatric caregiver to understand the condition and the treatment options available. RECENT FINDINGS The majority of patients are women, and presentation is usually with symptoms of persistent nausea, emesis, postprandial pain and bloating, and early satiety. Weight loss may occur in some cases, though this is not universal. The majority of cases are idiopathic, with diabetes mellitus the second most common cause. SUMMARY Treatment consists of symptomatic relief with medication to counteract the nausea, emesis, pain, bloating, gastroesophageal reflux, early satiety, and improve gastric emptying. Dietary modification is also used with small meals and avoidance of high fiber and fat-containing foods. Recalcitrant cases of gastroparesis require the use of additional approaches such as jejunal feeds, intrapyloric botulinum toxin, gastric emptying procedures such as pyloroplasty, and gastric electrical stimulation. We will review these options in this article.
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Abstract
The cellular abnormalities that lead to diabetic gastroparesis are increasingly being understood. Several key cell types are affected by diabetes, leading to gastroparesis. These changes include abnormalities in the extrinsic innervation to the stomach, loss of key neurotransmitters at the level of the enteric nervous system, smooth muscle abnormalities, loss of interstitial cells of Cajal, and changes in the macrophage population resident in the muscle wall. This article reviews the current understanding with a focus on data from human studies when available.
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Affiliation(s)
- Gianrico Farrugia
- Enteric NeuroScience Program, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Abstract
Understanding of gastroparesis is evolving, in part because of systematic studies on the pathology, pathophysiology, and outcomes. It is clear that simply accelerating gastric emptying may not effectively control symptoms in this syndrome and more creative approaches are required that address aberrant sensation (vagal and spinal) as well as regional disturbances in motility. Further, with the growing recognition of a possible inflammatory basis, the prospects of disease modifying now seem realistic.
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Affiliation(s)
- Pankaj Jay Pasricha
- Department of Medicine, Johns Hopkins Center for Neurogastroenterology, Johns Hopkins School of Medicine, 720 Rutland Street, Ross 958, Baltimore, MD 21205, USA.
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Hu B, Ye H, Sun C, Zhang Y, Lao Z, Wu F, Liu Z, Huang L, Qu C, Xian L, Wu H, Jiao Y, Liu J, Cai J, Chen W, Nie Z, Liu Z, Chen C. Metoclopramide or domperidone improves post-pyloric placement of spiral nasojejunal tubes in critically ill patients: a prospective, multicenter, open-label, randomized, controlled clinical trial. Crit Care 2015; 19:61. [PMID: 25880172 PMCID: PMC4367875 DOI: 10.1186/s13054-015-0784-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 02/03/2015] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION The use of prokinetic agents on post-pyloric placement of spiral nasojejunal tubes is controversial. The aim of the present study was to examine if metoclopramide or domperidone can increase the success rate of post-pyloric placement of spiral nasojejunal tubes. METHODS A multicenter, open-label, randomized, controlled trial was conducted in seven hospitals in China between April 2012 and February 2014. Patients admitted to the intensive care unit and requiring enteral nutrition for more than three days were randomly assigned to the metoclopramide, domperidone or control groups (1:1:1 ratio). The primary outcome was defined as the success rate of post-pyloric placement of spiral nasojejunal tubes, assessed 24 hours after initial placement. Secondary outcomes included success rate of post-D1, post-D2, post-D3 and proximal jejunum placement and tube migration distance. Safety of the study drugs and the tubes during the entire study period were recorded. RESULTS In total, 307 patients were allocated to the metoclopramide (n = 103), domperidone (n = 100) or control group (n = 104). The success rate of post-pyloric placement after 24 hours in the metoclopramide, domperidone and control groups was 55.0%, 51.5% and 27.3%, respectively (P = 0.0001). Logistic regression analysis identified the use of prokinetic agents, Acute Physiology and Chronic Health Evaluation (APACHE) II score <20, Sequential Organ Failure Assessment (SOFA) score <12 and without vasopressor as independent factors influencing the success rate of post-pyloric placement. No serious drug-related adverse reaction was observed. CONCLUSIONS Prokinetic agents, such as metoclopramide or domperidone, are effective at improving the success rate of post-pyloric placement of spiral nasojejunal tubes in critically ill patients. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR-TRC-12001956 . Registered 21 February 2012.
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Affiliation(s)
- Bei Hu
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Heng Ye
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Cheng Sun
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Yichen Zhang
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Zhigang Lao
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19 Nonglinxia Road, Guangzhou, 510080, Guangdong, PR China.
| | - Fanghong Wu
- Department of Critical Care Medicine, Jiangmen Wuyi Traditional Chinese Medicine Hospital, 30 Huayuandong Road, Jiangmen, 529000, Guangdong, PR China.
| | - Zhaohui Liu
- Department of Critical Care Medicine, Guangdong Armed Police Hospital, 106 Yanling Road, Guangzhou, 510507, Guangdong, PR China.
| | - Linxi Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Shantou University Medical Collage, 57 Changping Road, Shantou, 515041, Guangdong, PR China.
| | - Changchun Qu
- Department of Critical Care Medicine, Guangdong Yunfu People's Hosipital, 120 Huanshidong Road, Yunfu, 527300, Guangdong, PR China.
| | - Lewu Xian
- Department of Critical Care Medicine, Cancer Center of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong, PR China.
| | - Hao Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19 Nonglinxia Road, Guangzhou, 510080, Guangdong, PR China.
| | - Yingjie Jiao
- Department of Critical Care Medicine, Jiangmen Wuyi Traditional Chinese Medicine Hospital, 30 Huayuandong Road, Jiangmen, 529000, Guangdong, PR China.
| | - Junling Liu
- Department of Critical Care Medicine, Guangdong Armed Police Hospital, 106 Yanling Road, Guangzhou, 510507, Guangdong, PR China.
| | - Juyu Cai
- Department of Critical Care Medicine, The First Affiliated Hospital of Shantou University Medical Collage, 57 Changping Road, Shantou, 515041, Guangdong, PR China.
| | - Weiying Chen
- Department of Critical Care Medicine, Guangdong Yunfu People's Hosipital, 120 Huanshidong Road, Yunfu, 527300, Guangdong, PR China.
| | - Zhiqiang Nie
- Department of Cardiovascular Epidemiology, Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Zaiyi Liu
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Chunbo Chen
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
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Phillips LK, Deane AM, Jones KL, Rayner CK, Horowitz M. Gastric emptying and glycaemia in health and diabetes mellitus. Nat Rev Endocrinol 2015; 11:112-28. [PMID: 25421372 DOI: 10.1038/nrendo.2014.202] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rate of gastric emptying is a critical determinant of postprandial glycaemia and, accordingly, is fundamental to maintaining blood glucose homeostasis. Disordered gastric emptying occurs frequently in patients with longstanding type 1 diabetes mellitus and type 2 diabetes mellitus (T2DM). A complex bidirectional relationship exists between gastric emptying and glycaemia--gastric emptying accounts for ∼35% of the variance in peak postprandial blood glucose concentrations in healthy individuals and in patients with diabetes mellitus, and the rate of emptying is itself modulated by acute changes in glycaemia. Clinical implementation of incretin-based therapies for the management of T2DM, which diminish postprandial glycaemia, in part by slowing gastric emptying, is widespread. Other therapies for patients with T2DM, which specifically target gastric emptying include pramlintide and dietary-based treatment approaches. A weak association exists between upper gastrointestinal symptoms and the rate of gastric emptying. In patients with severe diabetic gastroparesis, pathological changes are highly variable and are characterized by loss of interstitial cells of Cajal and an immune infiltrate. Management options for patients with symptomatic gastroparesis remain limited in their efficacy, which probably reflects the heterogeneous nature of the underlying pathophysiology.
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Affiliation(s)
- Liza K Phillips
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Adam M Deane
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Karen L Jones
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Chris K Rayner
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
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Phillips LK, Rayner CK, Jones KL, Horowitz M. Measurement of gastric emptying in diabetes. J Diabetes Complications 2014; 28:894-903. [PMID: 25047170 DOI: 10.1016/j.jdiacomp.2014.06.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 06/10/2014] [Indexed: 02/07/2023]
Abstract
There has been a substantial evolution of concepts related to disordered gastric emptying in diabetes. While the traditional focus has hitherto related to the pathophysiology and management of upper gastrointestinal symptoms associated with gastroparesis, it is now apparent that the rate of gastric emptying is central to the regulation of postprandial glycemia. This recognition has stimulated the development of dietary and pharmacologic approaches to optimize glycemic control, at least in part, by slowing gastric emptying. With the increased clinical interest in this area, it has proved necessary to expand the traditional indications for gastric emptying studies, and consider the relative strengths and limitations of available techniques. Scintigraphy remains the 'gold standard' for the measurement of gastric emptying, however, there is a lack of standardization of the technique, and the optimal test meal for the evaluation of gastrointestinal symptoms may be discordant from that which is optimal to assess impaired glycemic control. The stable isotope breath test provides an alternative to scintigraphy and can be performed in an office-based setting. The effect of glucagon-like peptide-1 (GLP-1) and its agonists to reduce postprandial glycemia is dependent on the baseline rate of gastric emptying, as well as the magnitude of slowing. Because the effect of exogenous GLP-1 to slow gastric emptying is subject to tachyphylaxis with sustained receptor exposure, 'short acting' or 'prandial' GLP-1 agonists primarily target postprandial glycemia through slowing of gastric emptying, while 'long acting' or 'non-prandial' agents lower fasting glucose primarily through insulinotropic and glucagonostatic mechanisms. Accordingly, the indications for the therapeutic use of these different agents are likely to vary according to baseline gastric emptying rate and glycemic profiles.
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Affiliation(s)
- Liza K Phillips
- Discipline of Medicine, The University of Adelaide, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Australia
| | - Chris K Rayner
- Discipline of Medicine, The University of Adelaide, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Australia
| | - Karen L Jones
- Discipline of Medicine, The University of Adelaide, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Australia
| | - Michael Horowitz
- Discipline of Medicine, The University of Adelaide, Australia; NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Australia.
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Qiu X, Lin M, Zhang Y. Trimebutine maleate combined with domperidone for treatment of diabetic gastroparesis. Shijie Huaren Xiaohua Zazhi 2014; 22:4478-4481. [DOI: 10.11569/wcjd.v22.i29.4478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the clinical effects of trimebutine maleate combined with domperidone in the treatment of diabetic gastroparesis (DGP).
METHODS: Eighty-six patients with DGP were randomly divided into either an experiment group or a control group. The experiment group was treated with trimebutine maleate combined with domperidone, and the control group was treated with domperidone alone. The clinical effects, gastric emptying half-time (GET1/2), adverse reactions, and relapse were compared for the two groups.
RESULTS: The total effective rate for the experiment group was significantly higher than that for the control group (93.02% vs 74.42%, P < 0.05). The GET1/2 post-treatment for the two groups was significantly lower than that prior-treatment (124.49 min ± 23.05 min vs 225.62 min ± 21.88 min, 199.46 min ± 23.49 min vs 222.62 min ± 19.08 min, P < 0.05). There was no significant difference in the rate of adverse reactions for the two groups (0.00% vs 4.65%, P > 0.05). The rate of relapse at 2 mo for the experiment group was lower than that for the control group (13.95% vs 51.16%, P < 0.05).
CONCLUSION: Trimebutine maleate combined with domperidone can improve clinical symptoms and GET1/2 in patients with DGP.
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Endoscopic versus bedside electromagnetic-guided placement of nasoenteral feeding tubes in surgical patients. J Gastrointest Surg 2014; 18:1664-72. [PMID: 24981659 DOI: 10.1007/s11605-014-2582-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/20/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nasoenteral tube feeding is often required in surgical patients, mainly because of delayed gastric emptying. Bedside electromagnetic (EM)-guided tube placement by specialized nurses might offer several advantages (e.g., reduced patient discomfort and costs) over conventional endoscopic placement. The aim of this study was to compare the success rate of EM-guided to endoscopic placement of nasoenteral feeding tubes in surgical patients. MATERIALS AND METHODS A retrospective cohort study was performed in 267 adult patients admitted to two gastrointestinal surgical wards who received a nasoenteral feeding tube by EM-guidance or endoscopy. Eighteen patients were excluded because of insufficient data. Patients were categorized according to the primary tube placement method. Subgroup analysis was performed in patients with altered upper gastrointestinal anatomy. Primary endpoint was successful tube placement at or beyond the duodenojejunal flexure. RESULTS A total of 249 patients were included, of which 90 patients underwent EM-guided and 159 patients underwent endoscopic tube placement. Both groups were comparable for baseline characteristics. Primary tube placement was successful in 74/90 patients (82 %) in the EM-guided group versus 140/159 patients (88 %) in the endoscopic group (P = 0.20). In patients with altered upper gastrointestinal anatomy, success rates were significantly lower in the EM-guided group (58 vs. 86 %, P = 0.004). There were no significant differences in tube-related complications such as dislodgement or tube blockage. CONCLUSIONS Bedside EM-guided placement of nasoenteral feeding tubes by specialized nurses did not differ from endoscopic placement by gastroenterologists regarding feasibility and safety in surgical patients with unaltered upper gastrointestinal anatomy.
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Dhakal OP, Dhakal M, Bhandari D. Phytobezoar leading to gastric outlet obstruction in a patient with diabetes. BMJ Case Rep 2014; 2014:bcr-2013-200661. [PMID: 24928925 DOI: 10.1136/bcr-2013-200661] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Gastroparesis is a condition which results in delayed gastric emptying without gastric outflow tract obstruction. Gastrointestinal involvement in diabetes can present in various forms such as oesophageal dysmotility, gastro-oesophageal reflux disease, gastroparesis, enteropathy, non-alcoholic fatty liver disease and glycogenic hepatopathy. Gastroparesis is the most common gastric motility disorder complicating long-standing diabetes. It can sometimes lead to mechanical obstruction as a result of formation of bezoars. Phytobezoars are the most common type of bezoar and are composed of indigestible food, vegetable fibre or seeds. Poor pyloric function and decreased acid formation predisposes phytobezoars formation in patients with diabetic gastroparesis. An 80-year-old patient with diabetes in our presentation developed gastric outlet obstruction due to impaction of phytobezoar over the pylorus.
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Affiliation(s)
- Om Prakash Dhakal
- Department of Medicine, Sikkim Manipal Institute of Medical Science, Gangtok, Sikkim, India
| | - Mona Dhakal
- Department of Medicine, Sikkim Manipal Institute of Medical Science, Gangtok, Sikkim, India
| | - Dhurba Bhandari
- Department of Microbiology, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim, India
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Kundu S, Rogal S, Alam A, Levinthal DJ. Rapid improvement in post-infectious gastroparesis symptoms with mirtazapine. World J Gastroenterol 2014; 20:6671-6674. [PMID: 24914393 PMCID: PMC4047357 DOI: 10.3748/wjg.v20.i21.6671] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/10/2014] [Accepted: 03/05/2014] [Indexed: 02/06/2023] Open
Abstract
We report the case of a 34-year-old woman with severe post-infectious gastroparesis who was transferred from an outside medical facility for a second opinion regarding management. This patient had no prior history of gastrointestinal symptoms. However, in the aftermath of a viral illness, she developed two months of intractable nausea, vomiting, and oral intake intolerance that resulted in numerous hospitalizations for dehydration and electrolyte disturbances. A solid-phase gastric emptying scan had confirmed delayed emptying, confirming gastroparesis. Unfortunately, conventional pro-kinetic agents and numerous anti-emetic drugs provided little or no relief of the patient’s symptoms. At our institution, the patient experienced a cessation of vomiting, reported a significant reduction in nausea, and tolerated oral intake shortly after taking mirtazapine. Based on mirtazapine’s primary action as a serotonin (5-HT) 1a receptor agonist, we infer that this receptor system mediated the clinical improvement through a combination of peripheral and central neural mechanisms. This report highlights the potential utility of 5-HT1a agonists in the management of nausea and vomiting. We conclude that mirtazapine may be effective in treating symptoms associated with non-diabetic gastroparesis that are refractory to conventional therapies.
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