Nausea and vomiting in gastroparesis: similarities and differences in idiopathic and diabetic gastroparesis

BACKGROUND

Nausea and vomiting are classic symptoms of gastroparesis. It remains unclear if characteristics of nausea and vomiting are similar in different etiologies of gastroparesis. The aims of this article were as follows: to describe characteristics of nausea and vomiting in patients with gastroparesis and to determine if there are differences in nausea and vomiting in diabetic (DG) and idiopathic gastroparesis (IG).

METHODS

Gastroparetic patients enrolling in the NIDDK Gastroparesis Registry underwent assessment with history and questionnaires assessing symptoms, quality of life, and a questionnaire characterizing nausea and vomiting.

KEY RESULTS

Of 159 gastroparesis patients (107 IG, 52 DG), 96% experienced nausea, whereas 65% experienced vomiting. Nausea was predominant symptom in 28% and vomiting was predominant in 4%. Nausea was severe or very severe in 41%. PAGI-SYM nausea/vomiting subscore was greater with increased vomiting severity, but not nausea severity in DG than IG. Nausea was related to meals in 71%; lasting most of the day in 41%. Increasing nausea severity was related to decreased quality of life. Nausea often preceded vomiting in 82% of patients and vomiting often relieved nausea in 30%. Vomiting was more common in DG (81%) compared to IG (57%; p = 0.004). Diabetic patients more often had vomiting in the morning before eating, during the night, and when not eating.

CONCLUSIONS & INFERENCES

Nausea is present in essentially all patients with gastroparesis irrespective of cause and associated with decreased quality of life. In contrast, vomiting was more prevalent, more severe, and occurred more often in DG than IG. Thus, characteristics of vomiting differ in IG vs DG.

Factors related to abdominal pain in gastroparesis: contrast to patients with predominant nausea and vomiting

BACKGROUND

Factors associated with abdominal pain in gastroparesis are incompletely evaluated and comparisons of pain vs other symptoms are limited. This study related pain to clinical factors in gastroparesis and contrasted pain/discomfort- with nausea/vomiting-predominant disease.

METHODS

Clinical and scintigraphy data were compared in 393 patients from seven centers of the NIDDK Gastroparesis Clinical Research Consortium with moderate-severe (Patient Assessment of Upper Gastrointestinal Disorders Symptoms [PAGI-SYM] score ≥ 3) vs none-mild (PAGI-SYM < 3) upper abdominal pain and predominant pain/discomfort vs nausea/vomiting.

KEY RESULTS

Upper abdominal pain was moderate-severe in 261 (66%). Pain/discomfort was predominant in 81 (21%); nausea/vomiting was predominant in 172 (44%). Moderate-severe pain was more prevalent with idiopathic gastroparesis and with lack of infectious prodrome (P ≤ 0.05) and correlated with scores for nausea/vomiting, bloating, lower abdominal pain/discomfort, bowel disturbances, and opiate and antiemetic use (P < 0.05), but not gastric emptying or diabetic neuropathy or control. Gastroparesis severity, quality of life, and depression and anxiety were worse with moderate-severe pain (P ≤ 0.008). Factors associated with moderate-severe pain were similar in diabetic and idiopathic gastroparesis. Compared to predominant nausea/vomiting, predominant pain/discomfort was associated with impaired quality of life, greater opiate, and less antiemetic use (P < 0.01), but similar severity and gastric retention.

CONCLUSIONS & INFERENCES

Moderate-severe abdominal pain is prevalent in gastroparesis, impairs quality of life, and is associated with idiopathic etiology, lack of infectious prodrome, and opiate use. Pain is predominant in one fifth of gastroparetics. Predominant pain has at least as great an impact on disease severity and quality of life as predominant nausea/vomiting.

Clinical-histological associations in gastroparesis: results from the Gastroparesis Clinical Research Consortium

BACKGROUND

Cellular changes associated with diabetic (DG) and idiopathic gastroparesis (IG) have recently been described from patients enrolled in the Gastroparesis Clinical Research Consortium. The association of these cellular changes with gastroparesis symptoms and gastric emptying is unknown. The aim of this study was to relate cellular changes to symptoms and gastric emptying in patients with gastroparesis.

METHODS

Earlier, using full thickness gastric body biopsies from 20 DG, 20 IG, and 20 matched controls, we found decreased interstitial cells of Cajal (ICC) and enteric nerves and an increase in immune cells in both DG and IG. Here, demographic, symptoms [gastroparesis cardinal symptom index score (GCSI)], and gastric emptying were related to cellular alterations using Pearson's correlation coefficients.

KEY RESULTS

Interstitial cells of Cajal counts inversely correlated with 4 h gastric retention in DG but not in IG (r = -0.6, P = 0.008, DG, r = 0.2, P = 0.4, IG). There was also a significant correlation between loss of ICC and enteric nerves in DG but not in IG (r = 0.5, P = 0.03 for DG, r = 0.3, P = 0.16, IG). Idiopathic gastroparesis with a myenteric immune infiltrate scored higher on the average GCSI (3.6 ± 0.7 vs 2.7 ± 0.9, P = 0.05) and nausea score (3.8 ± 0.9 vs 2.6 ± 1.0, P = 0.02) as compared to those without an infiltrate.

CONCLUSIONS & INFERENCES

In DG, loss of ICC is associated with delayed gastric emptying. Interstitial cells of Cajal or enteric nerve loss did not correlate with symptom severity. Overall clinical severity and nausea in IG is associated with a myenteric immune infiltrate. Thus, full thickness gastric biopsies can help define specific cellular abnormalities in gastroparesis, some of which are associated with physiological and clinical characteristics of gastroparesis.

The impact of sickle cell trait on glycated haemoglobin in diabetes mellitus

AIMS

To determine the effect of sickle cell trait on measurement of glycated haemoglobin (HbA(1c)) in African American patients with diabetes mellitus.

METHODS

This is a retrospective study including 885 outpatients who underwent HbA(1c) testing. Medical record review and sickle cell trait determinations based on the HbA(1c) assay were performed in African American participants. The relationship between HbA(1c) and serum glucose measurements was analysed.

RESULTS

Data were obtained from 385 AA (109 with SCT, 22 with haemoglobin C trait and 254 without haemoglobinopathy) and 500 European American patients. In a model created through multivariate repeated-effects regression, the relationship between HbA(1c) and simultaneous serum glucose did not differ between African American subjects with and without the sickle cell trait, but differed between African American subjects without the sickle cell trait and European Americans (P = 0.0002).

CONCLUSIONS

Sickle cell trait does not impact the relationship between HbA(1c) and serum glucose concentration. In addition, it does not appear to account for ethnic difference in this relationship between African Americans and whites.

Glucose ingestion causes GLUT4 translocation in human skeletal muscle

In humans, ingestion of carbohydrates causes an increase in blood glucose concentration, pancreatic insulin release, and increased glucose disposal into skeletal muscle. The underlying molecular mechanism for the increase in glucose disposal in human skeletal muscle after carbohydrate ingestion is not known. We determined whether glucose ingestion increases glucose uptake in human skeletal muscle by increasing the number of glucose transporter proteins at the cell surface and/or by increasing the activity of the glucose transporter proteins in the plasma membrane. Under local anesthesia, approximately 1 g of vastus lateralis muscle was obtained from six healthy subjects before and 60 min after ingestion of a 75-g glucose load. Plasma membranes were isolated from the skeletal muscle and used to measure GLUT4 and GLUT1 content and glucose transport in plasma membrane vesicles. Glucose ingestion increased the plasma membrane content of GLUT4 per gram muscle (3,524 +/- 729 vs. 4,473 +/- 952 arbitrary units for basal and 60 min, respectively; P < 0.005). Transporter-mediated glucose transport into plasma membrane vesicles was also significantly increased (130 +/- 11 vs. 224 +/- 38 pmol.mg-1.s-1; P < 0.017), whereas the calculated ratio of glucose transport to GLUT4, an indication of transporter functional activity, was not significantly increased 60 min after glucose ingestion (2.3 +/- 0.4 vs. 3.0 +/- 0.5 pmol.GLUT4 arbitrary units-1.s-1; P < 0.17). These results demonstrate that oral ingestion of glucose increases the rate of glucose transport across the plasma membrane and causes GLUT4 translocation in human skeletal muscle. These findings suggest that under physiological conditions the translocation of GLUT4 is an important mechanism for the stimulation of glucose uptake in human skeletal muscle.

Carbohydrate metabolism during pregnancy in control subjects and women with gestational diabetes

The purpose of this study was to characterize carbohydrate metabolism associated with the development of gestational diabetes. Six control (Ctl) and ten women with gestational diabetes mellitus (GDM) were evaluated using an intravenous glucose tolerance test and hyperinsulinemic-euglycemic clamp with [6,6-2H2]glucose prior to conception (P) and at 12-14 (E), and 34-36 wk of gestation (L). There was an increase (P = 0.0001) in first-phase insulin response in Ctl (P 174 +/- 133, E 388 +/- 120, and L 587 +/- 303 microU/ml) and GDM (P 197 +/- 94, E 267 +/- 77, and L 376 +/- 162 microU/ml) but a significant (P = 0.02) lag in change in GDM with advancing gestation. Basal endogenous glucose production increased during gestation [Ctl: P 2.74 +/- 0.23, E 2.62 +/- 0.38, and L 3.14 +/- 0.36; GDM: P 2.68 +/- 0.51, E 2.78 +/- 0.45, and L 2.98 +/- 0.48 mg.kg fat-free mass (FFM)-1 x min-1; P = 0.02], but there was resistance to suppression by insulin infusion (P = 0.03) in late gestation (GDM: 0.61 +/- 0.44 vs. Ctl: 0.16 +/- 0.17 mg.kg FFM-1 x min-1). Insulin sensitivity decreased during gestation (Ctl: P 10.78 +/- 2.78, E 8.34 +/- 2.36, and L 4.75 +/- 1.22; GDM: P 7.49 +/- 2.13, E 7.40 +/- 1.45, and L 4.21 +/- 1.01 mg.kg FFM-1 x min-1; P = 0.0001) and was primarily decreased (P = 0.04) in GDM compared with Ctl from P through E. These findings closely resemble those of non-insulin-dependent, predominantly insulin-resistant diabetes, which is often a sequel of GDM.

Aerobic fitness and resting energy expenditure in young adult males

Ambiguous findings have been reported in previous studies regarding the relationships among aerobic fitness, resting metabolic rate (RMR), and the thermic effect of a meal (TEM). We reexamined the association among these variables in young nonobese men who exhibited a wide range of aerobic fitness levels. RMR was measured after an overnight fast and TEM was assessed for three hours after ingestion of a liquid meal. Preprandial and postprandial plasma levels of insulin, glucose, and thyroid hormones (total T3 and T4) were measured. Daily energy intake was estimated from three-day food diaries, body composition from underwater weighing, and aerobic fitness from a test of VO2 max. Data were analyzed with linear and curvilinear regression analysis, as well as with ANOVA to test for differences among subjects classified by fitness level (ie, untrained, moderately, and highly trained). A significant correlation was found between RMR and VO2 max (r = .77, P less than .01). RMR adjusted for body weight and FFW was higher in highly trained men when compared to moderately and untrained individuals. However, a curvilinear relationship was found between TEM and VO2 max (P less than .05). Subjects who exhibited moderate levels of fitness showed the highest TEM, whereas a lower TEM was noted in untrained and highly trained men. These findings were observed in the absence of differences in plasma concentrations of total T3 and T4 among fitness levels. These findings suggest that highly trained men have a high RMR adjusted for their metabolic size.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased efficiency of weight gain and altered cellularity of brown adipose tissue in rats with impaired glucose tolerance during diet-induced overfeeding

We examined the relationship among glucose tolerance, efficiency of weight gain, and cellularity of brown adipose tissue (BAT) in rats (initial weight: 362 +/- 1 g) made hyperphagic and obese by feeding on a highly palatable "cafeteria" (CAF) diet for 4-8 wk. As compared with chow-fed controls, CAF feeding resulted in a 45-60% increase in caloric intake (P less than 0.01), a 40-50% increase in weight gain (P less than 0.01), and hyperinsulinemia. Glucose disposal rate (K) on intravenous glucose tolerance test (IVGTT) was greater than or equal to 1.4% in all chow-fed rats, but fell to less than or equal to 1.3 in 10 of 23 CAF-fed rats. As compared with the chow-fed controls, rats with normal glucose tolerance demonstrated a 12% decline in efficiency of weight gain (g/100 kcal of food consumed) in response to CAF feeding (P less than 0.05). In marked contrast, in rats with impaired glucose tolerance, efficiency of weight gain failed to decline in response to overfeeding and was 18% higher than in the overfed group with normal glucose tolerance (P less than 0.01). Although CAF feeding increased the mass of interscapular BAT by 110-130% in rats with normal as well as impaired glucose tolerance, DNA content of BAT rose only in the normal-K CAF-fed rats (0.19 +/- 0.01 mg DNA/100 mg versus 0.12 +/- 0.02 in chow-fed controls and 0.12 +/- 0.01 in low-K rats).(ABSTRACT TRUNCATED AT 250 WORDS)

Glucose turnover during recovery from intensive exercise

This study was undertaken to examine glucose turnover during a 30-min recovery period following an acute bout of intensive exercise (85% VO2 max) performed to exhaustion (11.7 ± 1.4 min). Plasma glucose (basal 85 ± 2 mg/dl) rose by 10 mg/dl at exhaustion and increased further during the initial phase of recovery, reaching a peak value of 35 mg/dl above basal at 5 min of recovery. Thereafter, there was a gradual decline, but the values remained 15–20 mg/dl above basal at 30 min. The early rise in plasma glucose during recovery was due to an imbalance between glucose production and utilization caused by a more rapid decline in utilization than production. At 5 min of recovery, glucose production was fivefold greater than in the basal state and comparable to peak values observed at exhaustion, while glucose utilization was 33% lower than observed at exhaustion and only 75% higher than in the basal state. Beyond 5 min of recovery glucose utilization and production again differed in the direction of response. Glucose production fell to basal values while glucose utilization remained 70–80% above baseline. The maintenance of basal rates of glucose production and increased rates of glucose utilization occurred in a setting in which plasma insulin levels were increased by 25–50%. Plasma catechol-amines, which rose 5–10-fold during exercise, fell rapidly during the initial 3 min of recovery.

We conclude that recovery from exhaustive exercise is characterized by a biphasic imbalance between glucose production and utilization in which production exceeds utilization for the initial 5 min and utilization exceeds production at 10–30 min. The hormone-substrate milieu (modest increments in plasma insulin and glucose) accompanying the changes in glucose kinetics observed beyond 5 min suggests that the recovery period from acute exercise may be characterized by an increase in peripheral sensitivity to insulin, which could provide a mechanism for facilitating muscle glycogen repletion during recovery from intensive exercise.