Gastroparesis: New insights into an old disease

Mechanism of action of FoxiangSan in diabetic gastroparesis: Gut microbiota and cAMP/PKA pathway

Diabetic gastroparesis, a common complication of type 2 diabetes (T2DM), presents a significant treatment challenge. FoxiangSan is emerging as a potential therapy. FoxiangSan is a traditional Chinese medicine formula with the potential for treating diabetic gastroparesis by modulating gut microbiota and cAMP/PKA signaling pathways. This study explores the mechanisms behind FoxiangSan's effects on T2DM-induced gastroparesis, focusing on its impact on gut microbiota and the cAMP/PKA pathway. A rat model of type 2 diabetic gastroparesis was established through a high-fat diet and streptozotocin (STZ) injection, and the effects of FoxiangSan were assessed. Additionally, protein expression related to the cAMP/PKA pathway was examined, and FoxiangSan's influence on gut microbiota was studied using 16S rRNA sequencing. FoxiangSan significantly alleviated hyperglycemia, improved gastric pathology in rats with gastroparesis, enhanced the expression of 5-HT4, cAMP, PKA, and pPKA in the gastric antrum, and rebalanced gut microbiota. FoxiangSan demonstrates the therapeutic potential for T2DM-associated gastroparesis by modulating the cAMP/PKA pathway and gut microbiota.

Endoscopic pyloromyotomy for treatment of gastroparesis: A new standard or still an experimental approach?

Gastroparesis (GP) can be a severe and debilitating disease. Its pathophysiology is complex and not completely understood. Two principal mechanisms are responsible for the development of symptoms - gastric hypomotility and pylorospasm. Pylorus targeted therapies aim to decrease presumably elevated pyloric tone - pylorospasm. There is a growing body of evidence about their role in the treatment algorithm of GP. G-POEM (endoscopic pyloromyotomy) is an extensively studied pylorus targeted therapy. Its efficacy ranges between 56 and 80% and the number of recurrences among those with treatment effect seems low. G-POEM is a safe procedure with very low frequency of severe adverse events. At present, G-POEM should not be considered as an experimental approach and may be offered to all patients with refractory and severe GP. Nevertheless, G-POEM is not a first line treatment. Conservative measures such as diet modification and pharmacotherapy should always be tried before G-POEM is considered. Further research must focus on better patient selection as at present there are no standardized criteria. Functional imaging such as impedance planimetry (EndoFlip) may hold promise in this regard.

Current and emerging pharmacotherapy for the treatment of gastroparesis

INTRODUCTION

Gastroparesis is a chronic disorder characterized by decreased gastric emptying and presents with nausea, vomiting, and abdominal pain which impacts patients' quality of life greatly. The treatment modalities available for gastroparesis have been expanding over the past 2 decades. Currently, there are multiple options available for gastroparesis, albeit with only one FDA-approved medication until June 2021.

AREAS COVERED

We review the different treatments available for gastroparesis and discuss the recently FDA-approved intranasal formulation of metoclopramide. This nasal spray guarantees metoclopramide absorption within 15 min of application bypassing first pass metabolism in the liver and overcoming the limitations of the oral formulation not passing into the small intestine for absorption because of a gastroparetic stomach or a patient unable to take the oral metoclopramide because of nausea and vomiting.

EXPERT OPINION

We now find ourselves in an oasis after spending many years in a 'desert' regarding pharmacologic therapies available for gastroparesis. The expansion of the research involving dopamine receptor antagonists and delving into alternative mechanisms of alleviating gastroparesis symptoms has been crucial in the landscape of gastroparesis. This is especially true as our knowledge of gastroparesis has proven that simply improving gastric emptying does not necessarily translate to clinical improvement.

Pathogenesis and management of diabetic gastroparesis: An updated clinically oriented review

BACKGROUND AND AIMS

Diabetic gastroparesis (DGp) is a common and preventable complication of uncontrolled diabetes mellitus (D.M.) and significantly affects the Quality of Life of patients. Diagnosis and management present as a clinical challenge due to the disease's complexity and limited effective therapeutic options. This review aims to comprehensively outline the pathogenesis, diagnosis, and management of diabetic gastroparesis, evaluating evolving approaches to guide clinicians and provide future recommendations.

METHODS

A literature review was conducted on scholarly databases of PubMed, Google Scholar, Scopus and Web of Science encompassing published articles, gray literature and relevant clinical guidelines. Data were synthesized and analyzed to provide a comprehensive overview of diabetic gastroparesis, focusing on pathogenesis, diagnosis, and management.

RESULTS

The review intricately explores the pathogenesis contributing to diabetic gastroparesis, emphasizing autonomic neuropathy, oxidative stress, inflammation, hormonal dysregulation, microbiota alterations, and gastrointestinal neuropathy. Primary management strategies are underscored, including lifestyle modifications, symptom relief, and glycemic control. The discussion encompasses pharmacological and surgical options, highlighting the importance of a multidisciplinary approach involving various healthcare professionals for comprehensive patient care.

CONCLUSION

This review offers a thorough understanding of pathogenesis, diagnosis, and management of diabetic gastroparesis, underlining evolving approaches for clinicians. A multidisciplinary approach is crucial to address both the physical and mental health aspects of diabetes and its complications.

Risk factor analysis and nomogram for predicting gastroparesis in patients with type 2 diabetes mellitus

Purpose

The incidence of gastroparesis is higher in individuals diagnosed with type 2 diabetes mellitus (T2DM) compared to the healthy individuals. Our study aimed to explore the risk factors for gastroparesis in T2DM and to establish a clinical prediction model (nomogram).

Methods

Our study enlisted 694 patients with T2DM from two medical centers over a period of time. From January 2020 to December 2022, 347 and 149 patients were recruited from the Beilun branch of Zhejiang University's First Affiliated Hospital in the training and internal validation cohorts, respectively. The external validation cohort consisted of 198 patients who were enrolled at Nanchang University's First Affiliated Hospital from October 2020 to September 2021. We conducted univariate and multivariate logistic regression analyses to select the risk factors for gastroparesis in patients with T2DM; subsequently,we developed a nomogram model. The performance of the nomogram was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), calibration curve, and decision curve analysis(DCA).

Results

Four clinical variables, including age, regular exercise, glycated hemoglobin level(HbA1c), and Helicobacter pylori (H. pylori) infection, were identified and included in the model. The model demonstrated excellent discrimination, with an AUC of 0.951 (95% CI = 0.925-0.978) in the training group, and 0.910 (95% CI = 0.859-0.961) and 0.875 (95% CI = 0.813-0.937) in the internal and external validation groups, respectively. The calibration curve showed good consistency between prediction of the model and observed gastroparesis. The DCA also demonstrated good clinical efficacy.

Conclusion

The nomogram model developed in this study showed good performance in predicting gastroparesis in patients with T2DM.

Smart capsules for sensing and sampling the gut: status, challenges and prospects

Smart capsules are developing at a tremendous pace with a promise to become effective clinical tools for the diagnosis and monitoring of gut health. This field emerged in the early 2000s with a successful translation of an endoscopic capsule from laboratory prototype to a commercially viable clinical device. Recently, this field has accelerated and expanded into various domains beyond imaging, including the measurement of gut physiological parameters such as temperature, pH, pressure and gas sensing, and the development of sampling devices for better insight into gut health. In this review, the status of smart capsules for sensing gut parameters is presented to provide a broad picture of these state-of-the-art devices while focusing on the technical and clinical challenges the devices need to overcome to realise their value in clinical settings. Smart capsules are developed to perform sensing operations throughout the length of the gut to better understand the body's response under various conditions. Furthermore, the prospects of such sensing devices are discussed that might help readers, especially health practitioners, to adapt to this inevitable transformation in healthcare. As a compliment to gut sensing smart capsules, significant amount of effort has been put into the development of robotic capsules to collect tissue biopsy and gut microbiota samples to perform in-depth analysis after capsule retrieval which will be a game changer for gut health diagnosis, and this advancement is also covered in this review. The expansion of smart capsules to robotic capsules for gut microbiota collection has opened new avenues for research with a great promise to revolutionise human health diagnosis, monitoring and intervention.

The current state of gastrointestinal motility evaluation in cystic fibrosis: a comprehensive literature review

Background and Objective

As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential.

Methods

A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data.

Key Content and Findings

Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided.

Conclusions

The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.

A global bibliometric and visualized analysis of the status and trends of gastroparesis research

BACKGROUND

Gastroparesis has a substantial impact on the quality of life but has limited treatment options, which makes it a public health concern. No bibliometric studies on gastroparesis have been published thus far. Thus, this article aims to summarize and analyze research hotspots to provide a reference for clinical researchers.

MATERIALS AND METHODS

Gastroparesis-related research articles were searched in the Web of Science Core Collection (WOSCC), and relevant information was extracted after screening. A total of 1033 documents were analyzed with the bibliometric method using Microsoft Excel, Citespace, and VOSviewer.

RESULTS

Overall, our search retrieved 1033 papers contributed by 966 research institutions from 53 countries. Since 1980, publications in this field have increased rapidly. United States (n = 645) and Temple University (n = 122) were the most productive country and institution, respectively. Parkman, with 96 publications, was the most prominent author.

CONCLUSIONS

Research hotspots in gastroparesis can be summarized into four domains: innovation in diagnostic modalities, change of oral therapeutic agents, choice of surgical interventions, and pathological mechanisms. Future research on gastroparesis should focus on the quality of life of patients, diagnostic techniques, pyloromyotomy, and transpyloric stent placement.

Macrophage regulation of the "second brain": CD163 intestinal macrophages interact with inhibitory interneurons to regulate colonic motility - evidence from the Cx3cr1-Dtr rat model

Intestinal macrophages are well-studied for their conventional roles in the immune response against pathogens and protecting the gut from chronic inflammation. However, these macrophages may also have additional functional roles in gastrointestinal motility under typical conditions. This is likely to occur via both direct and indirect influences on gastrointestinal motility through interaction with myenteric neurons that contribute to the gut-brain axis, but this mechanism is yet to be properly characterised. The CX3CR1 chemokine receptor is expressed in the majority of intestinal macrophages, so we used a conditional knockout Cx3cr1-Dtr (diphtheria toxin receptor) rat model to transiently ablate these cells. We then utilized ex vivo video imaging to evaluate colonic motility. Our previous studies in brain suggested that Cx3cr1-expressing cells repopulate by 7 days after depletion in this model, so we performed our experiments at both the 48 hr (macrophage depletion) and 7-day (macrophage repopulation) time points. We also investigated whether inhibitory neuronal input driven by nitric oxide from the enteric nervous system is required for the regulation of colonic motility by intestinal macrophages. Our results demonstrated that CD163-positive resident intestinal macrophages are important in regulating colonic motility in the absence of this major inhibitory neuronal input. In addition, we show that intestinal macrophages are indispensable in maintaining a healthy intestinal structure. Our study provides a novel understanding of the interplay between the enteric nervous system and intestinal macrophages in colonic motility. We highlight intestinal macrophages as a potential therapeutic target for gastrointestinal motility disorders when inhibitory neuronal input is suppressed.

Diabetic Gastroparesis and its Emerging Therapeutic Options: A Narrative Review of the Literature

Diabetic gastroparesis (DG) is one of the many complications of diabetes mellitus (DM). Even though this condition surfaces years after uncontrolled disease, it affects the quality of life in several ways and causes significant morbidity. Common symptoms experienced by the patients include postprandial nausea, vomiting, abdominal fullness, and pain. Strict glycemic control is essential to evade the effects of DG. The purpose of this review article is to briefly study the pathophysiology, clinical features, diagnostic modalities, and the effects of DG on different aspects of life. Furthermore, it also focuses on the emerging treatment modalities for DG. Tradipitant and relamorelin are two such treatment options that are gaining noteworthy recognition and are discussed in detail in this review article. As observed through various clinical trials, these drugs help alleviate symptoms like nausea, vomiting, abdominal pain, and bloating in patients suffering from DG, thereby targeting the most common and bothersome symptoms of the disease. This leads to an improvement in the quality of life, making it a reliable treatment option for this disease. But while pharmacological intervention is vital, psychological support and lifestyle changes are equally important and are the reason why a multidisciplinary approach is required for the treatment of DG.

The role of gastric emptying in glucose homeostasis and defense against hypoglycemia: Innocent bystander or partner in crime?

Maintenance of plasma glucose (PG) homeostasis is due to a complex network system. Even a minor fall in PG activates multiple neuroendocrine actions promoting hormonal, metabolic and behavioral responses, which prevent and ultimately recover hypoglycemia, primarily neuroglycopenia. Among these responses, gastric emptying (GE) plays an important role by coordinated mechanisms which regulate transit and absorption of nutrients through the small intestine. A bidirectional relationship between GE and glycemia has been established: GE may explain the up to 30-40 % variance in glycemic response following a carbohydrate-rich meal. In addition, acute and chronic hyperglycemia induce deceleration of GE after meals. Hypoglycemia accelerates GE, but its role in counterregulation has been poorly investigated. The role of GE as a counterregulatory mechanism has been confirmed in pathophysiological conditions, such as gastroparesis or following recurrent hypoglycemia. Therefore, it could represent an "ancestral" mechanism, highly conservative and effective in all individuals, conditions and clinical contexts. Recent guidelines recommend GLP-1 receptor agonists (GLP-1RAs) either as the first injectable therapy for type 2 diabetes mellitus or in combination with insulin. Considering the potential impact on GE, it would be important to study subjects on GLP-1 RAs during hypoglycemia, to establish whether a possible deceleration of GE impairs glucose counterregulation.

The Impact of Microbiota on the Gut-Brain Axis: Examining the Complex Interplay and Implications

The association and interaction between the central nervous system (CNS) and enteric nervous system (ENS) is well established. Essentially ENS is the second brain, as we call it. We tried to understand the structure and function, to throw light on the functional aspect of neurons, and address various disease manifestations. We summarized how various neurological disorders influence the gut via the enteric nervous system and/or bring anatomical or physiological changes in the enteric nervous system or the gut and vice versa. It is known that stress has an effect on Gastrointestinal (GI) motility and causes mucosal erosions. In our literature review, we found that stress can also affect sensory perception in the central nervous system. Interestingly, we found that mutations in the neurohormone, serotonin (5-HT), would result in dysfunctional organ development and further affect mood and behavior. We focused on the developmental aspects of neurons and cognition and their relation to nutritional absorption via the gastrointestinal tract, the development of neurodegenerative disorders in relation to the alteration in gut microbiota, and contrariwise associations between CNS disorders and ENS. This paper further summarizes the synergetic relation between gastrointestinal and neuropsychological manifestations and emphasizes the need to include behavioral therapies in management plans.

The effect of single and repeated doses of rivastigmine on gastric myoelectric activity in experimental pigs

BACKGROUND

Rivastigmine is a pseudo-irreversible cholinesterase inhibitor used for therapy of Alzheimer's disease and non-Alzheimer dementia syndromes. In humans, rivastigmine can cause significant gastrointestinal side effects that can limit its clinical use. The aim of this study was to assess the impact of rivastigmine on gastric motor function by means of electrogastrography (EGG) in experimental pigs.

METHODS

Six experimental adult female pigs (Sus scrofa f. domestica, hybrids of Czech White and Landrace breeds; 3-month-old; mean weight 30.7 ± 1.2 kg) were enrolled into the study twice and created two experimental groups. In group A, a single intragastric dose of 6 mg rivastigmine hydrogen tartate was administered in the morning to fasting pigs before EGG recording. In group B, rivastigmine was administered to overnight fasting animals in a dietary bolus in the morning for 7 days (6 mg per day). On day 8, an intragastric dose of 12 mg rivastigmine was given in the morning to fasting pigs before EGG. EGG recording was accomplished by means of an EGG standalone system. Recordings from both groups were evaluated in dominant frequency and EGG power (areas of amplitudes).

RESULTS

In total, 1,980 one-minute EGG intervals were evaluated. In group A, basal EGG power (median 1290.5; interquartile range 736.5-2330 μV2) was significantly higher in comparison with the power of intervals T6 (882; 577-1375; p = 0.001) and T10 (992.5; 385-2859; p = 0.032). In group B, the dominant frequency increased significantly from basal values (1.97 ± 1.57 cycles per minute) to intervals T9 (3.26 ± 2.16; p < 0.001) and T10 (2.14 ± 1.16; p = 0.012), respectively. In group B, basal EGG power (median 1030.5; interquartile range 549-5093) was significantly higher in comparison with the power of intervals T7 (692.5; 434-1476; p = 0.002) and T8 (799; 435-1463 μV2; p = 0.004).

CONCLUSIONS

Both single as well as repeated intragastric administration of rivastigmine hydrogen tartrate caused a significant decrease of EGG power (areas of amplitudes) in experimental pigs. EGG power may serve as an indirect indicator of gastric motor competence. These findings might provide a possible explanation of rivastigmine-associated dyspepsia in humans.

Unveiling the Unprecedented: An Astonishing Rarity of Metoclopramide Hydrochloride-Triggered Nystagmus in a Pregnant Woman

Metoclopramide hydrochloride is a widely used medication for the treatment of gastrointestinal disorders such as nausea, vomiting, and gastroparesis. However, it has been associated with extrapyramidal side effects (EPS) such as tardive dyskinesia, nystagmus, and other locomotive disorders on rare occasions. These reactions are commonly seen in children and females, particularly in young people. In this article, we report a rare case of a 15-week pregnant woman who was prescribed metoclopramide hydrochloride in view of nausea and vomiting, which was later diagnosed as vomiting in pregnancy not relieved with first-line medications, and has later developed drug-induced nystagmus, highlighting its unpredictable nature and shortcomings of management in the pregnant woman. This article will draw the attention of obstetricians and gynecologists to wisely prescribe metoclopramide hydrochloride for treating nausea and vomiting in pregnant women.

A prediction nomogram for postoperative gastroparesis syndrome in right colon cancer: a retrospective study

PURPOSE

To investigate the high-risk factors for postoperative gastroparesis syndrome (PGS) in right colon cancer and to build a prediction nomogram for personalized prediction of PGS.

METHODS

Our study retrospectively analyzed 361 patients with right colon cancer who underwent right hemicolectomy at The First Hospital of Putian City in Fujian Province, China and who were hospitalized between January 2012 and July 2022. Multivariate logistic regression was used to determine the independent risk factors for PGS and to establish a nomogram model. Furthermore, discrimination, calibration, and clinical benefits were used to evaluate the model.

RESULTS

The multivariate logistic regression revealed that dissection of the subpyloric lymph nodes (No. 206 lymph node) (OR 5.242, P = 0.005), preoperative fasting blood glucose level (OR 3.708, P = 0.024), preoperative albumin level (OR 3.503, P = 0.020), and total operative time (OR 4.648, P = 0.014) were independent risk factors for PGS. Based on the above four factors, the area under the ROC curve (AUC) and C-index of the nomogram were 0.831. The prediction nomogram's calibration curve was closer to the ideal diagonal, and the Hosmer‒Lemeshow test indicated that the nomogram fit well (P = 0.399). Moreover, the decision curve analysis revealed that the model can present better clinical benefits when the threshold probability was between 1 and 28%, and the internal validation verified the dependability of the model (C-index = 0.948).

CONCLUSIONS

A risk prediction nomogram based on perioperative factors provided the physician with a simple, visual, and efficient tool for the prediction and management of PGS in right colon cancer.

Factors Affecting Delayed Gastric Emptying and Long-Term Outcomes of Children With Gastric Emptying

OBJECTIVES

Our study attempted to identify what factors best predict for delayed gastric emptying (DGE) and whether children respond to treatment.

METHODS

Children aged between 0 and 18 were included who had a gastric emptying scintigraphy (GES) study performed between 2009 and 2018. Baseline clinical details were recorded from clinic visit records regarding symptoms, medication, and past medical history. Results were analyzed using multivariate regression analysis and coefficient analysis. Children were followed up at 2 years to assess their symptoms and medication usage.

RESULTS

Two hundred and eighty-five children were included in the study of which 174 demonstrated DGE. All children had symptoms prior to GES, the most common symptom being that of vomiting and reflux symptoms which were present in over 90% of patients; other common symptoms like abdominal pain and nausea were seen commonly in around 30%. A genetic disorder and prior surgery were more common in children with DGE but there was no difference in presenting symptoms between normal and DGE groups. Regression analysis showed prior surgery and particularly prior abdominal surgery predicted for DGE and additionally predicted for those with highly DGE. Improvement in symptoms and reduction in medication usage was seen after 2 years.

CONCLUSIONS

This study provides one of the largest data sets looking at DGE in children. Prior surgery was found to be a key factor in predicting for highly DGE. Symptoms and medication usage did significantly reduce substantially after 2 years.

Gastroparesis-Related Symptoms in Patients With Type 2 Diabetes Mellitus: Early Detection, Risk Factors, and Prevalence

Background The symptoms of gastroparesis, such as bloating, postprandial fullness, early satiety, nausea, and abdominal discomfort, progressively worsen the quality of life of the affected individuals. The diagnosis is established on the assessment of gastric function that confirms delayed gastric emptying in the absence of structural etiologies. This study aimed to detect gastroparesis-related clinical symptoms early in patients with type 2 diabetes mellitus (T2DM), investigate the concomitant risk factors, and evaluate the prevalence. Methodology This study was conducted at the Department of Medicine and Diabetes Outdoor Clinic of Sheikh Zayed Hospital, Rahim Yar Khan from February 13, 2022, to February 11, 2023. The study involved 175 patients with T2DM who reported gastroparesis-related symptoms. The demographic and clinical characteristics, symptom severity, complications, related risk factors, duration of disease, medications, body mass index (BMI), fasting plasma glucose, and glycated hemoglobin (HbA1C) levels were assessed. The severity of diabetic gastroparesis was established using the disease-specific Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) and the Gastroparesis Cardinal Symptom Index (GCSI). The five-point scale of the PAGI-SYM and the four-degree severity scores of GCSI were assessed. Neuropathy disability scores and motor evacuation functions were analyzed. Data were analyzed from these questionnaires, special proforma, and patient interviews. Results The clinical features of diabetic gastroparesis were observed in 44% of T2DM patients with mild-grade gastroparesis in 38 (21.7%), moderate in 30 (17.1%), and severe-grade gastroparesis-related symptoms in nine (5.2%) patients. The main manifestations were early satiety (45.1%), stomach fullness (44.5%), bloating (38.3%), and nausea (33.1%). Diabetic gastroparesis symptoms were considerably linked to disease duration of more than 10 years (p = 0.02), high HbA1c (p = 0.001), increased fasting blood glucose (p = 0.003), polyneuropathy, cigarette smoking, and history of comorbid conditions (p = 0.009). Obesity and the female gender were the forecasters of the manifestation of at least one cardinal gastroparesis symptom. Conclusions Gastric emptying is significant in the pathogenesis of gastroparesis-related symptoms. Disease duration of more than 10 years, poor glycemic control with hyperglycemia, high HbA1C, polyneuropathy, and cigarette smoking must be considered as predictors for early detection and risk factors for the advancement of gastroparesis in T2DM. Gastroparesis-related common symptoms of early satiety, bloating, and stomach fullness were considerably linked to the additional risk factors of hypercholesteremia, chronic microvascular complications, concomitant cardiovascular diseases, and a positive family history of diabetes mellitus. There was no relationship between BMI, age, types of treatment, and the degree of gastroparesis severity. The prevalence and severity of gastroparesis symptoms were particularly high among obese females with poor glycemic control and longer disease duration.

Prevalence of small intestinal bacterial overgrowth in patients with gastroparesis: a systematic review and meta-analysis

Aim

We performed a systematic review and meta-analysis to identify the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with gastroparesis.

Background

Several studies have suggested an association between SIBO and gastroparesis, which is characterized by delayed gastric emptying in the absence of mechanical obstruction.

Methods

A comprehensive search was performed using MEDLINE, EMBASE, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) through January, 2022 for randomized controlled trials and observational studies reporting the prevalence of SIBO in gastroparesis. Pooled prevalence was estimated using a random effects model. Heterogeneity was assessed by using the inconsistency index (I2).

Results

Among the 976 articles identified, 43 studies were selected for full text review. Six studies, with 385 patients, were deemed eligible for inclusion, with a perfect agreement between investigators (kappa=1.0). Overall, 379 patients were diagnosed with gastroparesis by gastric emptying scintigraphy and six were diagnosed with a wireless motility capsule. The pooled prevalence of SIBO was 41% (95% confidence interval 0.23-0.58). SIBO was diagnosed using jejunal aspirate cultures (N=15, 8.4%), lactulose breath test (N=80, 44.7%), glucose breath test (N=30, 16.8%), D-xylose breath test (N=52, 29.1%), and hydrogen breath test (N=2, 1.1%). Heterogeneity was significant and noted to be high at 91%. Only one study reported SIBO diagnosis in controls, therefore no pooled odds ratio was calculated.

Conclusion

SIBO was present in almost half of the patients with gastroparesis. Future studies should examine and identify the association between SIBO and gastroparesis.

Gastrointestinal involvement in systemic sclerosis: An updated review

The gastrointestinal tract (GI) is the second most affected organ system in individuals suffering from systemic/localized scleroderma (SSc) or localized scleroderma. SSc can affect any part of the GI, between the oral cavity and anorectum. The annual incidence of SSc in the United States is estimated to be 19.3 cases per million adults, with the highest incidence reported in people aged 44 to 55. Females are 5 times more likely than males to suffer from SSc. Morbidity and mortality rates associated with SSc are predominantly elevated among patients with GI manifestations. Esophageal and intestinal manifestations impact 90% and 40% to 70% of patients with systemic scleroderma, respectively. SSc patients are known to suffer from small bowel hypomotility and small intestinal bacterial overgrowth, which cause malabsorption and malnutrition, ultimately contributing to the 50% mortality rate. Fecal incontinence is a common symptom of SSc that can lead to depression. SSc patients may suffer from gastrointestinal complications that can negatively impact their quality of life on a daily basis. Multidisciplinary approaches are necessary for systematically managing gastrointestinal complications associated with SSc. A prospective study should focus on developing targeted therapies to improve recovery patterns and prognosis in cases of SSc. This article summarizes the epidemiology, commonly reported clinical manifestations, complications, and available treatments for treating GI pathology in SSc patients.

Efficacy and Safety of Domperidone in Combination with Proton Pump Inhibitors in Gastroesophageal Reflux Disease: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

The aims of gastroesophageal reflux disease (GERD) treatment are symptom relief and healing of oesophagitis. Besides proton pump inhibitors (PPIs), prokinetic agents are also commonly prescribed to treat GERD. Domperidone, a well-known antiemetic, is an example of a prokinetic agent. It is a dopaminergic blocker that increases lower oesophagus sphincter pressure and activates gastric motility. We carried out a systematic review and meta-analysis to explore the benefits of domperidone in addition to PPI therapy for GERD. We searched for publications comparing PPI plus domperidone to PPI monotherapy in terms of symptom improvement in GERD (until 21 April 2022) on PubMed, Scopus, Google Scholar, Web of Science, Cochrane Library, WHO’s International Clinical Studies Registry Platform, and ClinicalTrials.gov without restricting date, language, or study design. The protocol was registered in PROSPERO (CRD42021242076). This meta-analysis incorporated 11 studies with a total of 841 participants (419 in the PPI plus domperidone group and 422 in the PPI monotherapy group). The combination of a PPI and domperidone resulted in a significant reduction in global GERD symptoms. Adverse events associated with PPI plus domperidone treatment were similar to those associated with PPI monotherapy. In conclusion, the combination of domperidone and a PPI is generally safe and effective in treating GERD as compared with that of PPI alone.

The Potential of Electrical Stimulation and Smart Textiles for Patients with Diabetes Mellitus

Diabetes mellitus is one of the most frequent diseases in the general population. Electrical stimulation is a treatment modality based on the transmission of electrical pulses into the body that has been widely used for improving wound healing and for managing acute and chronic pain. Here, we discuss recent advancements in electroceuticals and haptic/smart devices for quality of life and present in which patients and how electrical stimulation may prove to be useful for the treatment of diabetes-related complications.

Vomiting and Gastric Motility in Early Brain Damaged Children With Congenital Zika Syndrome

OBJECTIVES

This study investigated the occurrence of vomiting and gastric dysmotility in dysphagic children with congenital Zika syndrome (CZS) and assessed possible associations of these findings with the severity of dysphagia and the presence of tube feeding.

METHODS

Forty-six children with CZS were assessed for dysphagia, and the occurrence of vomiting, dietary volume tolerance <15 mL/kg, and feeding time per meal >30 minutes were evaluated. Gastric antrum ultrasonography was used to detect the frequency of contractions and measure antral areas (at fasting and 15 minutes postprandial), from which the gastric emptying rate (GER) was calculated. Antral ultrasonography findings were compared with those of ten healthy controls. Vomiting and gastric motility were compared between CZS patients according to the severity of dysphagia and the requirement for tube feeding.

RESULTS

Overall, 76% (35/46) of children with CZS had moderate-to-severe dysphagia (MSD), among whom 60% (21/35) were tube fed [MSD tube fed (MSDTF)]. Vomiting occurred in 54% (25/46) of children, whereas dietary volume intolerance and prolonged feeding time were observed in 59% (27/46) and 37% (17/46), respectively, most frequently in MSDTF patients. On ultrasound, 61% (28/46) of children with CZS had no antral contractions, whereas 90% (9/10) of controls did. Compared to healthy controls, GER was eight-fold lower in children with CZS and 60-fold lower in MSDTF children.

CONCLUSIONS

In dysphagic children with CZS, vomiting, volume intolerance, and prolonged feeding time were frequent and possibly associated with impaired antral contraction and delayed gastric emptying, especially in cases of severe dysphagia and tube feeding.

The pharmacokinetics of oral trazpiroben (TAK-906) after organic anion transporting polypeptide 1B1/1B3 inhibition: A phase I, randomized study

Trazpiroben is a dopamine D₂/D₃ receptor antagonist under development for the treatment of gastroparesis. This phase I, open‐label, randomized, two‐way crossover study (NCT04121078) evaluated the effect of single‐dose intravenous rifampin, a potent inhibitor of the organic anion transporting polypeptides (OATPs) 1B1 and 1B3, on the pharmacokinetics and safety of trazpiroben in healthy adults. The utility of coproporphyrin (CP) I and CPIII as biomarkers of OATP inhibition was also assessed. Overall, 12 participants were enrolled and randomized (1:1) into one of two treatment sequences (AB and BA). Participants received either a single oral dose of trazpiroben 25 mg (treatment A) or a single oral dose of trazpiroben 25 mg immediately after a single 30‐min intravenous infusion of rifampin 600 mg (treatment B). After a washout period of at least 7 days, participants received the other treatment. Geometric mean area under the curve from time 0 extrapolated to infinity (AUC_∞) and maximum serum concentration (C_max) of plasma trazpiroben were higher in participants receiving treatment B than those receiving treatment A (AUC_∞, 168.5 vs. 32.68 ng*h/ml; C_max, 89.62 vs. 14.37 ng/ml); corresponding geometric mean ratios (90% confidence interval) showed 5.16 (4.25–6.25) and 6.24 (4.62–8.42)‐fold increases in these parameters, respectively. In this study, trazpiroben was confirmed as a substrate of OATP1B1/1B3, and therefore co‐administration of trazpiroben with moderate to strong inhibitors of OATP1B1/1B3 is not recommended. This is also the first assessment of the utility of CPI and CPIII as endogenous biomarkers of OATP1B1/1B3 inhibition after a single intravenous dose of rifampin.

Gastroesophageal reflux disease: When East meets West

Gastroesophageal reflux disease (GERD) is common worldwide and poses a huge challenge to health. Consensuses and guidelines on the diagnosis and management of GERD in China and the USA have recently been updated. The divergence between these guidelines indicates the differences in the conception of this disease by experts in different countries, and is influenced by available medications and interventional procedures. Prompt endoscopy has been advocated in China due to a high prevalence of upper gastrointestinal (GI) cancer, while endoscopy has been reserved for those who are at a risk of malignancy or who are reisitant to proton pump inhibitors (PPIs) in the USA. A potassium channel acid-blocker is widely used in Asian countries and has proven efficacy. Moreover, it has been recommended, together with PPIs, as a primary therapy for GERD in China; while PPI alone is recommended as a first-line treatment in the USA. Although more prokinetics are available in China than in the USA and can alleviate GERD symptoms when combined with PPI, the choice of prokinetics is limited in the USA, leading to completely opposite attitudes to prokinetics in the two countries. Novel anti-reflux procedures have been introduced in both countries. Transoral incisionless fundoplication (TIF) is recommended as an endoscopic anti-reflux procedure, and magnetic sphincter augmentation (MSA) is recognized as equivocal to conventional laparoscopic fundoplication in the USA. However, radiofrequency ablation is more popular in China, and clinical trials on TIF and MSA are not complete, which results in diverse opinions about suitable anti-reflux procedures in China. A comparison of the guidelines may therefore shed light on the multiple dimensions of GERD and thus deepen our understanding of the disease.

Serial Measurements of Refractive Index, Glucose and Protein to Assess Gastric Liquid Nutrient Transport—A Proof-of-Principal Study

Delayed gastric emptying contributes to complications as aspiration or malnutrition. Among patients suffering from acute neurological diseases, motility disorders are prevalent but poorly understood. Thus, methods to measure gastric emptying are required to allow for appropriate adaptions of individual enteral nutrition algorithms. For enterally fed patients repetitive concentration measurements of gastric content have been proposed to assess gastric emptying. This approach can be used to calculate the gastric residual volume (GRV) and transport of nutrition formula (NF), but it has not yet been implemented in clinical routine. The aim of this study was to investigate whether refractometry or other likewise straightforward analytical approaches produce the best results under in vitro conditions mimicking the gastric milieu. We measured NF in different known concentrations, either diluted in water or in simulated gastric fluid (SGF), with each of the following methods: refractometer, handheld glucose meter, and Bradford protein assay. Then, in enterally fed patients suffering from acute neurological disease, we calculated GRVs and nutrition transport and tested possible associations with clinical parameters. In water dilution experiments, NF concentrations could be assessed with the readout parameters of all three methods. Refractometry yielded the most precise results over the broadest range of concentrations and was biased least by the presence of SGF (detection range for Fresubin original fibre, given as volume concentration/normalized error of regression slope after incubation with water or SGF: 0–100 vs. 0–100%/0.5 vs. 3.9%; glucose-measurement: 5–100 vs. 25–100%/7.9 vs. 6.1%; Bradford-assay: 0–100 vs. 0–100%/7.8 vs. 15.7%). Out of 28 enterally fed patients, we calculated significant slower nutrition transport in patients with higher blood glucose (Rho −0.391; p = 0.039) and in patients who received high-dose sufentanil (Rho −0.514; p = 0.005). Also, the calculated nutrition transport could distinguish patients with and without feeding intolerance (Median 6 vs. 17 ml/h; Mann-Whitney test: p = 0.002). The results of our study prove that serial refractometry is a suitable and cost-effective method to assess gastric emptying and to enhance research on gastrointestinal complications of stroke.

Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.

Comparative analysis of PIM criteria and drug labels in the elderly

PURPOSE

By discussing the corresponding situation of PIM criteria and labels, it provides a reference for the formulation and update of the criteria and the content of the section of "medications for the elderly" in the labels, so as to realize rational drug use for the elderly.

METHODS

Extract the four indicators of Beers criteria, STOPP criteria, and the EU(7)-PIM list that involve dosage, duration, age, and mortality, and compare them with the latest labels for drugs marketed in the USA and the EU.

RESULTS

There are 148 drugs involving four indicators in the criteria, and 85.14% of the drugs are found in at least one region. In terms of dose, there are 28 drugs with inconsistent descriptions in the labels of the two regions, accounting for 47.46% of the 59 drugs found in both regions. A total of 42.37% of the drugs are consistent in both regions with the criteria (25/59), 28.81% of the drugs are inconsistent in both regions with the criteria (17/59), and 28.81% of the drugs are inconsistent in only one region with the criteria (17/59). The doses of 50 drugs found in F/D labels are consistent with the criteria, accounting for 54.35% of the 92 drugs found in F/D labels, and of 41 drugs found in E/H SmPC are consistent with the criteria, accounting for 60.29% of the 68 drugs found in E/H SmPC. Only the duration of omeprazole in the labels in both regions is consistent with the criteria, and only the age of prasugrel in both regions is consistent with the criteria. Five drugs whose labels mentioned increased mortality, accounting for 38.46% of the 13 drugs found in both regions.

CONCLUSION

There are certain differences between PIM criteria and PIM criteria, labels and labels, and PIM criteria and labels, which will affect the use of drugs in the elderly. Therefore, the unity between the criteria and labels should be strengthened to provide more instructive guidance for the elderly, so as to jointly realize rational drug use in the elderly.

Gastroparesis: A Multidisciplinary Approach to Management

Gastroparesis is a neuromuscular disorder whose hallmark is delayed gastric emptying. It is a global challenge to the healthcare system because of poor treatment satisfaction for both the patients and clinicians, eventually leading to a reduction in the quality of life, with antecedent anxiety and depression. Although it is multifactorial in origin, diabetic, idiopathic, and drug-induced gastroparesis are the major risk factors. Disrupted interstitial cells of Cajal (ICC) and gastric dysrhythmia are pivotal to the pathogenesis, with most of the investigations targeted toward assessing gastric emptying and accommodation usually affected by distorted ICC and other neural networks. The treatment challenges can be overcome by a multidisciplinary approach involving gastroenterologists, gastrointestinal surgeons, biomedical engineers, nutritionists, psychologists, nurses, radionuclide radiologists, pharmacists, and family physicians. The exploration of the fundamental physiological processes underlying gastroparesis with the use of biomechanical materials should be given more attention by biomedical engineers to integrate innovative engineering with medicine for solving complex medical issues.

Refractory Gastroesophageal Reflux Disease: A Management Update

Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.

Short-term outcomes of different modalities of pyloromyotomy versus gastric electrical stimulation in the treatment of gastroparesis: A systemic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to compare the short-term outcomes surrounding the efficacy and complication rate between different modalities of pyloromyotomy and gastric electrical stimulation (GES) in the treatment of gastroparesis.

METHODS

Comprehensive, computerized research was performed on PubMed, Embase, and the Cochrane Central Register of Controlled Trials. We additionally reviewed relevant articles, without any language limitations, published prior to April 15, 2020. Meta-analysis was conducted using RevMan 5.3 software.

RESULTS

Three studies totaling 196 participants who had received 4 interventions, including single per-oral pyloromyotomy (POP), double POP, laparoscopic pyloromyotomy, and GES, were eligible for analysis. Compared to single POP, double POP achieved a better clinical response with a pooled relative risk (RR) of 1.27 (95% confidence interval [CI], 1.01-1.60, P = .04), while laparoscopic pyloromyotomy and GES showed no difference with a pooled RR of 0.89 (95% CI, 0.74-1.08, P = .23) and 0.87 (95% CI, 0.73-1.04, P = .13), respectively. As for the recurrence and complication rates, only GES showed a borderline significance of recurrence in comparison to single POP (RR 2.17, 95% CI, 1.00-4.71, P = .05), while there were no differences in the remainder of the comparisons.

CONCLUSIONS

We conducted a detailed comparison of 3 modalities of pyloromyotomy and GES in the treatment of gastroparesis, with the results suggesting that double POP demonstrated better clinical success with similar recurrence and complication rates. In addition, GES may result in more recurrence amongst these interventions.

Disorders of the brain-gut interaction and eating disorders

BACKGROUND

Eating disorders (ED) involve both the nervous system and the gastrointestinal tract. A similar double involvement is also found in disorders of the brain-gut interaction (DGBI) and symptoms are sometimes similar.

AIM

To find out where there is an association and a cause-effect relationship, we looked for the comorbidity of DGBI and ED.

METHODS

A systematic review was undertaken. A literature search was performed. Inclusion criteria for the articles retained for analysis were: Observational cohort population-based or hospital-based and case-control studies, examining the relationship between DGBI and ED. Exclusion criteria were: Studies written in other languages than English, abstracts, conference presentations, letters to the Editor and editorials. Selected papers by two independent investigators were critically evaluated and included in this review.

RESULTS

We found 29 articles analyzing the relation between DGBI and ED comprising 13 articles on gastroparesis, 5 articles on functional dyspepsia, 7 articles about functional constipation and 4 articles on irritable bowel syndrome.

CONCLUSION

There is no evidence for a cause-effect relationship between DGBI and ED. Their common symptomatology requires correct identification and a tailored therapy of each disorder.

Telocytes: An Emerging Component of Stem Cell Niche Microenvironment

Telocytes (TCs) are newly identified interstitial cells characterized by thin and long cytoplasmic processes, called telopodes, which exhibit a distinctive moniliform shape and, often, a sinuous trajectory. Telopodes typically organize in intricate networks within the stromal space of most organs, where they communicate with neighboring cells by means of specialized cell-to-cell junctions or shedding extracellular vesicles. Hence, TCs are generally regarded as supporting cells that help in the maintenance of local tissue homeostasis, with an ever-increasing number of studies trying to explore their functions both in physiological and pathological conditions. Notably, TCs appear to be part of stem cell (SC) niches in different organs, including the intestine, skeletal muscle, heart, lung, and skin. Indeed, growing evidence points toward a possible implication of TCs in the regulation of the activity of tissue-resident SCs and in shaping the SC niche microenvironment, thus contributing to tissue renewal and repair. Here, we review how the introduction of TCs into the scientific literature has deepened our knowledge of the stromal architecture focusing on the intestine and skeletal muscle, two organs in which the recently unveiled unique relationship between TCs and SCs is currently in the spotlight as potential target for tissue regenerative purposes.

Gastroparesis with Cannabis Use: A Retrospective Study from the Nationwide Inpatient Sample

Background: With increasing utilization of cannabis in the United States (US), clinicians may encounter more cases of Gastroparesis (GP) in coming years.Objective: The primary outcome was inpatient mortality for GP with cannabis use. Secondary outcomes included system-based complications and the burden of the disease on the US healthcare system.Methods: From the Nationwide Inpatient Sample (NIS), we identified adult hospitalizations with a primary discharge diagnosis of GP for 2016 and 2017. Individuals ≤18 years of age were excluded. The study population was subdivided based on a secondary diagnosis of cannabis use. The outcomes included biodemographic characteristics, mortality, complications, and burden of disease on the US healthcare system.Results: For 2016 and 2017, we identified 99,695 hospitalizations with GP. Of these hospitalizations, 8,870 had a secondary diagnosis of cannabis use while 90,825 served as controls. The prevalence of GP with cannabis use was 8.9%. For GP with cannabis use, the patients were younger (38.5 vs 48.1 years, p < 0.001) with a Black predominance (Table 1) and lower proportion of females (52.3 vs 68.3%, p < 0.001) compared to the non-cannabis use cohort. Additionally, the cannabis use cohort had higher percentage of patients with co-morbidities like hypertension, diabetes mellitus and a history of smoking. The inpatient mortality for GP with cannabis use was noted to be 0.27%. Furthermore, we noted shorter mean length of stay (LOS) (3.4 vs 4.4 days, aMD: -0.7, 95%CI: -0.9 - [-0.5], p < 0.001), lower mean total hospital charge (THC) ($30,400 vs $38,100, aMD: -5100, 95%CI: -6900 - [-3200], p < 0.001), and lower rates of sepsis (0.11 vs 0.60%, aOR: 0.22, 95% CI: 0.05-0.91, p = 0.036) for GP hospitalizations with cannabis use compared to the non-cannabis use cohort.Conclusion: Inpatient mortality for GP hospitalizations with cannabis use was 0.27%. Additionally, these patients had shorter LOS, lower THC, and lower sepsis rates.

COVID-19 infection manifesting as a severe gastroparesis flare: A case report

RATIONALE

Coronavirus disease 2019 (COVID-19) is a disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which commonly presents with symptoms including fever, cough, and dyspnea. More recently, however, some patients have tested positive for COVID-19 after developing gastrointestinal (GI) symptoms either solely or in conjunction with respiratory symptoms. This may be due to SARS-CoV-2 infection of the GI tract. In patients with chronic GI illnesses, COVID-19 may initially present as a flare of their underlying GI conditions as viruses have historically been implicated in exacerbations of GI disorders, including gastroparesis.

PATIENT CONCERNS

We report a case of a 37-year-old female with a history of diabetic gastroparesis who presented to the Emergency Department (ED) with nausea and vomiting similar to her gastroparesis flares.

DIAGNOSES

Her symptoms in the ED failed to improve with fluids and anti-emetic medications. After developing a fever, she was tested and found to be positive for COVID-19.

INTERVENTIONS

She was started on antibiotic, steroid, and antiviral medications.

OUTCOMES

Her symptoms improved, her fever defervesced on day 4 of hospitalization, and she was discharged on day 5 of hospitalization. The patient reported symptom improvement at a follow-up outpatient gastroenterology visit 2 months after hospitalization.

LESSONS

To the best of our knowledge, at the present time, this is the first report of a patient with COVID-19 presenting with signs and symptoms of a gastroparesis flare. This case illustrates that COVID-19 may present in an exacerbation of symptoms of an underlying disorder, such as a severe gastroparesis flare, in a patient with underlying gastroparesis. Initial presentation of these patients manifesting as a flare of their chronic GI disease, more severe than usual, should prompt an index of suspicion for COVID-19.

Diabetic and Non-Diabetic Gastroparesis: A Retrospective Comparative Outcome Study From the Nationwide Inpatient Sample

Background

Gastroparesis (GP), meaning “gastric palsy”, is a chronic medical condition characterized by delayed or absent gastric emptying in the absence of mechanical obstruction. The primary objective of this study was to determine the patient-specific outcomes and the burden of GP on the US healthcare system.

Methods

This was a population-based, retrospective study designed to analyze data available from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. Using the International Classification of Diseases, Tenth Revision (ICD-10) codes, we identified adult (18 years or older) hospitalizations with a principal diagnosis of GP. The study sample was further classified into two distinct groups based on the presence or absence of GP, namely diabetic GP (DGP) and non-diabetic GP (NDGP). The primary outcome of our study was inpatient mortality secondary to GP while the secondary outcomes included the odds of system-based complications and the burden of the disease on the United States healthcare system.

Results

We identified 99,695 adult (≥ 18 years) hospitalizations with a principal discharge diagnosis of GP in 2016 and 2017. Of these patients, 78.1% (77,885) had DGP and 21.9% (21,810) were classified in the NDGP group. We noted a higher proportion of women (79.3% vs. 63.4%, P < 0.001), patients with a history of smoking (35.8% vs. 31.7%, P < 0.001) and chronic obstructive pulmonary disease (10.7% vs. 7.6%, P < 0.001) in the NDGP group. After adjusting for common confounders excluding age, the inpatient mortality for GP was found to be 0.25%. Furthermore, after adjustments were made for the Charlson comorbidity index (CCI), we noted higher odds of mortality in the NDGP group (0.30% vs. 0.23%, adjusted odds ratio (aOR): 3.18, 95% confidence interval (CI): 1.75 - 5.79, P < 0.001) compared to the DGP group. Additionally, patients with NDGP had a higher mean length of stay (5 vs. 4.1 days, P < 0.001) and higher mean total hospital charge ($44,100 vs. $35,500, P < 0.001) compared to those with DGP. The NDGP group also had higher odds of sepsis, deep vein thrombosis (DVT) and pulmonary embolism (PE); however, the odds of developing acute kidney injury (AKI) were lower than that of the DGP group.

Conclusions

The inpatient mortality for GP was found to be 0.25%. After adjusting for CCI, patients with NDGP had higher odds of inpatient mortality compared to the DGP group. Additionally, patients with NDGP were associated with a longer length of hospital stay, mean total healthcare cost and higher odds of complications such as sepsis, DVT and PE during the hospitalization.

Efficacy and safety of complementary and alternative medicine therapy for gastroparesis: A protocol for systematic review and meta-analysis

BACKGROUND

Gastroparesis affects the quality of life of many patients, but there is no effective treatment. Now, complementary and alternative medicine originated from China is gradually accepted by the world because of its unique treatment principles and relatively safe treatment methods. However, at present, there is still a lack of more definitive clinical application evidence for the treatment of gastroparesis with complementary and alternative medicine to confirm the safety and efficacy of complementary and alternative medicine in the treatment of gastroparesis caused by various causes. More comprehensive and stronger evidence-based medicine evidence is needed.

METHODS

We will retrieve literatures using Medline, Embase, the Cochrane Library database, Web of science, CNKI, VIP, CBM, and WanFang. We will look for RCTs or CCTs on the use of complementary and alternative medicine in the treatment of gastroparesis, and extract relevant data into the excel sheet. The whole retrieval and data extraction process were carried out by 2 researchers independently. Then we will use meta-analysis to make statistical analysis of all the results and make a systematic review of all the included literatures.

RESULTS

All results and safety data were analyzed for a comprehensive evaluation and/or descriptive analysis of the efficacy and safety of complementary and alternative therapies for gastroparesis.

CONCLUSION

This study will provide more comprehensive clinical evidence for the treatment of gastroparesis with complementary and alternative therapies.

REGISTRATION

The research has been registered and approved on the INPLASY.COM website. The registration number is INPLASY2020100033.