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Varma R, Staab JP, Matey ET, Wright JA, Deb B, Lazaridis KN, Szarka LA, Bailey KR, Bharucha AE. Most patients with disorders of gut-brain interaction receive pharmacotherapy with major or moderate drug-gene interactions. Neurogastroenterol Motil 2024; 36:e14722. [PMID: 38072827 DOI: 10.1111/nmo.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND How variations predicted by pharmacogenomic testing to alter drug metabolism and therapeutic response affect outcomes for patients with disorders of gut- brain interaction is unclear. AIMS To assess the prevalence of pharmacogenomics-predicted drug-gene interactions and symptom outcomes for patients with disorders of gut-brain interaction. METHODS Patients who were treated in our clinical practice for functional dyspepsia/bowel disorder underwent pharmacogenomic testing. The change in symptoms from baseline to 6 months was compared for patients with variations in CYP2D6 and CYP2C19, which metabolize neuromodulators, and SLC6A4, which encodes the sodium- dependent serotonin transporter. RESULTS At baseline, 79 of 94 participants (84%) had at least one predicted major drug- gene interaction, and all 94 (100%) had at least one predicted moderate interaction. For the 44 participants who completed a survey of their symptoms at 6 months, the mean (SD) irritable bowel syndrome-symptom severity score decreased from 284 (71) at baseline to 231 (95) at 6 months (p < 0.001). Among patients taking selective serotonin reuptake inhibitors, the decrease in symptom severity (p = 0.03) and pain (p = 0.002) scores from baseline to 6 months was greater for patients with a homozygous SLC6A4 long/long genotype (n = 30) (ie, increased serotonin transporter activity) than for patients with homozygous short/short or heterozygous long/short genotypes (n = 64). Symptom outcomes were not affected by CYP2D6 or CYP2C19 variations. CONCLUSIONS The homozygous SLC6A4 long/long genotype confers better symptom resolution for patients with disorders of gut-brain interaction who take selective serotonin reuptake inhibitors than do the homozygous short/short or heterozygous long/short genotypes.
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Affiliation(s)
- Revati Varma
- Research Fellow in the Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric T Matey
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Brototo Deb
- Research Fellow in the Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Lawrence A Szarka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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White BA, Linder BJ, Szarka LA, Prichard DO. Urinary Symptoms and Bladder Voiding Dysfunction Are Common in Young Men with Defecatory Disorders: A Retrospective Evaluation. Dig Dis Sci 2022; 67:3036-3044. [PMID: 34292471 DOI: 10.1007/s10620-021-07167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS. METHODS We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction. RESULTS A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]). CONCLUSIONS Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.
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Affiliation(s)
- Bradley A White
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian J Linder
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Lawrence A Szarka
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - David O Prichard
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Sharma M, Lowry AC, Rao SS, Whitehead WE, Szarka LA, Hamilton FA, Bharucha AE. A multicenter study of anorectal pressures and rectal sensation measured with portable manometry in healthy women and men. Neurogastroenterol Motil 2021; 33:e14067. [PMID: 33462889 PMCID: PMC8169521 DOI: 10.1111/nmo.14067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The equipment and methods for performing anorectal manometry and biofeedback therapy are different and not standardized. Normal values are influenced by age and sex. Our aims were to generate reference values, examine effects of gender and age, and compare anorectal pressures measured with diagnostic and biofeedback catheters and a portable manometry system. METHODS In this multicenter study, anorectal pressures at rest, during squeeze, and evacuation were measured with diagnostic and biofeedback catheters using Mcompass™ portable device in healthy subjects. Balloon expulsion time and rectal sensation were evaluated. The effects of age and gender were assessed. RESULTS The final dataset comprised 108 (74 women) of 124 participants with normal rectal balloon expulsion time (less than 60 s). During squeeze, anal resting pressure increased by approximately twofold in women and threefold in men. During evacuation, anal pressure exceeded rectal pressure in 87 participants (diagnostic catheter). The specific rectoanal pressures (e.g., resting pressure) were significantly correlated and not different between diagnostic and biofeedback catheters. With the diagnostic catheter, the anal squeeze pressure and rectal pressure during evacuation were greater in men than women (p ≤ 0.02). Among women, women aged 50 years and older had lower anal resting pressure; rectal pressure and the rectoanal gradient during evacuation were greater in older than younger women (p ≤ 0.01). CONCLUSIONS Anal and rectal pressures measured with diagnostic and biofeedback manometry catheters were correlated and not significantly different. Pressures were influenced by age and sex, providing reference values in men and women.
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Affiliation(s)
- Mayank Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
| | - Ann C. Lowry
- Colon and Rectal Surgery Associates, Minneapolis, Mn
| | - Satish S. Rao
- Division of Gastroenterology, Augusta University, Augusta, Ga
| | - William E. Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | | | - Frank A. Hamilton
- National Institute of Digestive Diseases, Kidney, and Diabetes, Bethesda, MD
| | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Mn
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Al-Bawardy B, Kamboj AK, Desai S, Gorospe E, Bruining DH, Gostout CJ, Hansel SL, Larson MV, Murray JA, Nehra V, Leggett CL, Szarka LA, Watson RE, Rajan E. Patient-oriented education and visual-aid intervention are inadequate to identify patients with potential capsule retention: a prospective randomized study. Scand J Gastroenterol 2019; 54:662-665. [PMID: 31034255 DOI: 10.1080/00365521.2019.1608465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background/aims: The key procedure-related risk with video capsule endoscopy (VCE) is capsule retention, which should be suspected in patients who have not reported capsule passage. The study aims were to determine the frequency of capsule passage visualization and the difference in self-reporting of capsule passage between patients who receive patient-oriented education (POE) and patients who receive POE and a visual aid intervention in the form of a wrist band (WB). Methods: This was a prospective randomized study that enrolled patients undergoing VCE. Patients were randomly assigned to a POE group versus a POE and WB group. POE consisted of verbal education and an information booklet. Both groups received instructions to notify the study team regarding capsule passage. Results: Sixty patients (mean age 57 ± 18 years; 61% female) were included. A total of 57 patients were included in the analysis (3 lost to follow-up; 28 in POE group; 29 in WB group). Capsule passage status was reported by 68% without significant difference between POE and WB groups (72% vs. 64%; p = .51). Capsule passage status was obtained from all 57 patients with the addition of a proactive follow-up. Only 56% (n = 32) reported visualizing capsule passage. Of the remaining patients who did not visualize capsule passage, 60% (n = 15) reported on this without significant difference between the POE and WB groups (p = .23). Conclusions: Lack of visualization of capsule passage is a poor indicator of retention. Self-reporting of VCE passage status is suboptimal and the addition of a visual aid did not improve this parameter.
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Affiliation(s)
- Badr Al-Bawardy
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Amrit K Kamboj
- b Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Shiv Desai
- c Division of Gastroenterology and Hepatology , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Emmanuel Gorospe
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - David H Bruining
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | | | - Stephanie L Hansel
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Mark V Larson
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Joseph A Murray
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Vandana Nehra
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Cadman L Leggett
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Lawrence A Szarka
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Robert E Watson
- d Department of Radiology , Mayo Clinic , Rochester , MN , USA
| | - Elizabeth Rajan
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
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Abstract
There is substantial overlap between the symptoms of gastroparesis and a variety of alternative disorders. These conditions include rumination syndrome, drug-induced gastric emptying delay, cannabinoid hyperemesis syndrome, and eating disorders, which can be identified based on the history alone. The remaining patients require a diagnostic approach of physical examination, laboratory tests, evaluation with esophagogastroduodenoscopy or contrast radiography, and a test to measure gastric emptying. Symptomatic patients who have normal nutritional status and gastric emptying that is either normal or mildly delayed should be diagnosed with functional dyspepsia, whereas patients with moderate or severe gastric emptying delay are diagnosed with gastroparesis.
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Affiliation(s)
- Lawrence A Szarka
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Chedid V, Brandler J, Vijayvargiya P, Park SY, Szarka LA, Camilleri M. Characterization of Upper Gastrointestinal Symptoms, Gastric Motor Functions, and Associations in Patients with Diabetes at a Referral Center. Am J Gastroenterol 2019; 114:143-154. [PMID: 30166634 DOI: 10.1038/s41395-018-0234-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Our aim was to characterize upper gastrointestinal (UGI) symptoms and associations in individuals with diabetes mellitus (DM) who had undergone evaluation of gastric emptying (GE) and accommodation (GA) at a referral center. METHODS From the Mayo Clinic Rochester electronic medical records of adults with diabetes types 1 and 2 (DM1 and DM2) evaluated between January 1997 and December 2015, we extracted demographics, UGI symptoms, current medications, treatments for diabetes, GE solids by scintigraphy, GA by single photon emission computed tomography (SPECT), and diabetes complications. We compared subgroups with delayed (GE at 2 h <25% or GE at 4 h <75%), rapid (GE at 1 h > 35%), and normal GE, as well as reduced (<428 mL) and normal GA. RESULTS We reviewed 108 patients (60.2% females, median age 49.0 years). Overall, 71.3% had DM2; one-third of these were insulin dependent and had fairly well-controlled diabetes (median HbA1c 6.7% (IQR 6.2; 7.9)). Manifestations of diabetic triopathy (peripheral neuropathy, nephropathy, and retinopathy) were uncommon at presentation with UGI symptoms. Nausea was the most common symptom (80.6%). There were single or combined GE (total 56%: rapid in 37%, slow in 19%) and GA (total 39%) abnormalities; there was normal GA and GE in 28%; 40.3% of the DM2 patients had accelerated GE at 1 h. GE at 1 h is associated with nausea/vomiting, and fasting gastric volume is associated with bloating. CONCLUSIONS Among referred diabetic patients with UGI symptoms, GE and GA testing identifies potential targets for individualizing treatment and avoidance of empirical trials for the 28% with no disturbance of GE and GA.
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Affiliation(s)
- Victor Chedid
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - Justin Brandler
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - Priya Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - Seon-Young Park
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA.,Present address: Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, USA
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Lacy BE, Saito YA, Camilleri M, Bouras E, DiBaise JK, Herrick LM, Szarka LA, Tilkes K, Zinsmeister AR, Talley NJ. Effects of Antidepressants on Gastric Function in Patients with Functional Dyspepsia. Am J Gastroenterol 2018; 113:216-224. [PMID: 29257140 DOI: 10.1038/ajg.2017.458] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 10/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Functional dyspepsia (FD) is a highly prevalent functional bowel disorder. The effects of antidepressant therapy (ADTx) on gastric sensorimotor function in FD patients are poorly understood. AIMS Determine whether FD and subtypes with abnormalities in gastric function respond differently to ADTx compared to those with normal physiology. METHODS This multicenter, prospective trial randomized FD patients to 12 weeks of amitriptyline (AMI; 50 mg), escitalopram (ESC; 10 mg), or matching placebo. Demographics, symptoms, psychological distress, gastric emptying, and satiation were measured. Gastric accommodation (GA) using single-photon emission computed tomography imaging was performed in a subset of patients. An intent to treat analysis included all randomized subjects. The effect of treatment on gastric emptying was assessed using ANCOVA. A post hoc appraisal of the data was performed categorizing patients according to the Rome III subgrouping (PDS and EPS). RESULTS In total, 292 subjects were randomized; mean age=44 yrs. 21% had delayed gastric emptying. Neither antidepressant altered gastric emptying, even in those with baseline delayed gastric emptying. GA increased with ADTx (P=0.02). Neither antidepressant affected the maximal-tolerated volume (MTV) of the nutrient drink test although aggregate symptom scores improved compared to placebo (P=0.04). Patients with the combined EPS-PDS subtype (48%) had a lower MTV on the nutrient drink test compared to the EPS group at baseline (P=0.02). Postprandial bloating improved with both AMI (P=0.03) and ESC (P=0.02). CONCLUSIONS Amitriptyline (50 mg) improves FD symptoms but does not delay gastric emptying, even in patients with baseline delayed gastric emptying. GA improved with low-dose ADTx; the precise mechanism of action is unknown warranting further study.
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Affiliation(s)
- B E Lacy
- Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Y A Saito
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - M Camilleri
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - E Bouras
- Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - J K DiBaise
- Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - L M Herrick
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - L A Szarka
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K Tilkes
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - A R Zinsmeister
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - N J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
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Bazerbachi F, Haffar S, Szarka LA, Wang Z, Prokop LJ, Murad MH, Camilleri M. Secretory diarrhea and hypokalemia associated with colonic pseudo-obstruction: A case study and systematic analysis of the literature. Neurogastroenterol Motil 2017; 29. [PMID: 28580600 DOI: 10.1111/nmo.13120] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/30/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colonic pseudo-obstruction (CPO) is characterized by colonic distention in the absence of mechanical obstruction or toxic megacolon. Concomitant secretory diarrhea (SD) with hypokalemia (SD-CPO) due to gastrointestinal (GI) loss requires further characterization. AIM To perform a systematic review of SD-CPO, report a case study, and compare SD-CPO with classical CPO (C-CPO). METHODS We performed a search of MEDLINE, EMBASE, Cochrane, and Scopus for reports based on a priori criteria for CPO, SD and GI loss of potassium. An additional case at Mayo Clinic was included. RESULTS Nine publications met inclusion criteria, with a total of 14 cases. Six studies had high, three moderate, and our case high methodological quality. Median age was 74 years (66-97), with 2:1 male/female ratio. Kidney disease was present in 6/14 patients. Diarrhea was described as profuse, watery, or viscous in 10 patients. Median serum, stool, and urine potassium concentrations (mmol/L) were 2.4 (range: 1.9-3.1), 137 (100-180), and 17 (8-40), respectively. Maximal diameter of colon and cecum (median) were 10.2 cm and 10.5 cm, respectively. Conservative therapy alone was effective in five out of 14 patients. Median potassium supplementation was 124 mEq/d (40-300). Colonic decompression was effective in three out of six patients; one had a total colectomy; three out of 14 had died. The main differences between SD-CPO and C-CPO were lower responses to treatments: conservative measures (35.7% vs 73.6%, P=.01), neostigmine (17% vs 89.2%, P<.001), and colonic decompression (50% vs 82.4%, P=.02). CONCLUSION SD-CPO is a rare phenotype associated with increased fecal potassium and is more difficult to treat than C-CPO.
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Affiliation(s)
- F Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - S Haffar
- Digestive Center for Diagnosis and Treatment, Damascus, Syrian Arab Republic
| | - L A Szarka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Z Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - L J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - M H Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - M Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
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Rajan E, Gostout CJ, Wong Kee Song LM, Szarka LA, Kashyap PC, Smyrk TC, Bingener J, Deters JL, Knipschield MA, Bernard CE, Farrugia G. Innovative gastric endoscopic muscle biopsy to identify all cell types, including myenteric neurons and interstitial cells of Cajal in patients with idiopathic gastroparesis: a feasibility study (with video). Gastrointest Endosc 2016; 84:512-7. [PMID: 27129395 PMCID: PMC4991873 DOI: 10.1016/j.gie.2016.04.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The pathophysiology of some GI neuromuscular diseases remains largely unknown. This is in part due to the inability to obtain ample deep gastric wall biopsies that include the intermuscular layer of the muscularis propria (MP) to evaluate the enteric nervous system, interstitial cells of Cajal (ICCs), and related cells. We report on a novel technique for gastric endoscopic muscle biopsy (gEMB). METHODS Patients with idiopathic gastroparesis were prospectively enrolled in a feasibility study by using a novel "no hole" gEMB. Main outcome measures were technical success, adverse events, and histologic confirmation of the intermuscular layer, including myenteric neurons and ICC. The gEMB was a double resection clip-assist technique. A site was identified on the anterior wall of the gastric body as recommended by the International Working Group on histologic techniques. EMR was performed to unroof and expose the underlying MP. The exposed MP was then retracted into the cap of an over-the-scope clip. The clip was deployed, and the pseudopolyp of MP created was resected. This resulted in a no-hole gEMB. RESULTS Three patients with idiopathic gastroparesis underwent gEMB. Patients had severe delayed gastric emptying with a mean (± standard deviation [SD]) of 49 ± 16.8% of retained gastric contents at 4 hours. They had no history of gastric or small-bowel surgery and did not use steroids or other immunosuppressive drugs. The gEMB procedure was successfully performed, with no procedural adverse events. Postprocedural abdominal pain was controlled with nonsteroidal anti-inflammatory agents and opioid analgesics. Mean length of resected MP was 10.3 ± 1.5 mm. Mean procedure time was 25.7 ± 6 minutes. Hematoxylin and eosin (H&E) staining of tissue samples confirmed the presence of both inner circular and outer longitudinal muscle, as well as the intermuscular layer. H&E staining showed reduced myenteric ganglia in 1 patient. In 2 patients, specialized immunohistochemistry was performed, which showed a marked decrease in myenteric neurons as delineated by an antibody to protein gene product 9.5 and a severe decrease in ICC levels across the muscle layers. At 1 month follow-up, upper endoscopy showed a well-healed scar in 2 patients and minimal ulceration with a retained clip in 1 patient. CT of the abdomen confirmed the integrity of the gastric wall in all patients. Because of lack of an immune infiltrate in the resected samples, patients were not considered suitable for immunosuppressive or steroid therapy. CONCLUSIONS gEMB is feasible and easy to perform, with acquisition of tissue close to surgical samples to identify myenteric ganglia, ICCs, and multiple cell types. The ability to perform gEMB represents a paradigm shift in endoscopic tissue diagnosis of gastric neuromuscular pathologies.
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Affiliation(s)
| | | | | | - LA Szarka
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - PC Kashyap
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - TC Smyrk
- Division of Anatomic Pathology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - J Bingener
- Department of Surgery, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | | | | | - CE Bernard
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - G Farrugia
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
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Acosta A, Camilleri M, Linker-Nord S, Busciglio I, Iturrino J, Szarka LA, Zinsmeister AR. A Pilot Study of the Effect of Daikenchuto on Rectal Sensation in Patients with Irritable Bowel Syndrome. J Neurogastroenterol Motil 2015; 22:69-77. [PMID: 26486374 PMCID: PMC4699723 DOI: 10.5056/jnm15120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/17/2015] [Accepted: 09/19/2015] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Daikenchuto (TU 100), a botanical agent that modulates gastrointestinal nerves, is used in the treatment of motility and functional disorders. Our aim was to study the effects of TU-100 on rectal compliance and sensation in patients with irritable bowel syndrome (IBS). Methods In 20 patients per treatment arm, we conducted a single-center, randomized, parallel-group, double-blind, placebo-controlled, single-dose pharmacodynamics study evaluating the effects of TU-100, 15 g (5 g t.i.d. [means 3 times a day]), for 14–16 consecutive days on rectal compliance and rectal sensation (thresholds and sensation ratings), all measured at baseline and on the last day of medication treatment. The primary endpoint was rectal sensation thresholds and sensation ratings in response to balloon distension at 32 mmHg. Secondary endpoints were rectal compliance, sensation thresholds, ratings and tone (fasting and postprandial), bowel pattern, abdominal pain (average and worst severity) and bloating scores, IBS quality of life and safety profile. Results Rectal sensation ratings post-treatment were significantly associated with baseline (pre-treatment) ratings and with level of anxiety or stress recorded at the time of the sensation testing. There were no effects of TU-100 treatment on rectal sensation ratings, sensation thresholds, rectal fasting or postprandial tone, rectal compliance, bowel function, abdominal pain or bloating scores, or IBS quality of life. Conclusions TU-100 did not significantly affect rectal compliance and sensation in patients with IBS in this study.
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Affiliation(s)
- Andres Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Linker-Nord
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Irene Busciglio
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Johanna Iturrino
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Alan R Zinsmeister
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
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Acosta A, Camilleri M, Kolar G, Iturrino J, Szarka LA, Boldingh A, Burton D, Ryks M, Rhoten D, Zinsmeister AR, Spence SC, Gottesdiener K, Bouras EP, Vazquez-Roque MI. Relamorelin Relieves Constipation and Accelerates Colonic Transit in a Phase 2, Placebo-Controlled, Randomized Trial. Clin Gastroenterol Hepatol 2015; 13:2312-9.e1. [PMID: 26001337 DOI: 10.1016/j.cgh.2015.04.184] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/06/2015] [Accepted: 04/24/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Ghrelin receptors are located in the colon. Relamorelin is a pentapeptide selective agonist of ghrelin receptor 1a with gastric effects, but its effects in the colon are not known. We aimed to evaluate the effects of relamorelin on bowel movements (BMs) and gastrointestinal and colonic transit (CT) in patients with chronic constipation. METHODS We performed a study of 48 female patients with chronic constipation who fulfilled the Rome III criteria and had 4 or fewer spontaneous BMs (SBMs)/wk. In a randomized (1:1), double-blind, parallel-group, placebo-controlled trial, the effects of relamorelin (100 μg/d, given subcutaneously) were tested during 14 days after a 14-day baseline, single-blind phase in which patients were given placebo at 2 Mayo Clinic sites. The participants' mean age was 40.6 ± 1.5 y, with a mean body mass index of 25.7 ± 0.6 kg/m(2), with 1.7 ± 0.1 SBM/wk, and a mean stool consistency of 1.2 ± 0.1 on the Bristol scale during this baseline period. The effect of treatment on transit was measured in 24 participants with colonic transit of less than 2.4 (geometric center at 24 h) during the baseline period. Gastric emptying, small-bowel transit, and CT were measured during the last 2 days that patients received relamorelin or placebo. Bowel function was determined from daily diaries kept by patients from days 1 through 28. Study end points were time to first BM, SBMs/wk, complete SBMs/wk, stool form, and ease of stool passage. Effects of relamorelin were assessed by analysis of covariance. RESULTS Compared with placebo, relamorelin accelerated gastric emptying half-time (P = .027), small-bowel transit (P = .051), and CT at 32 hours (P = .040) and 48 hours (P = .017). Relamorelin increased the number of SBMs (P < .001) and accelerated the time to first BM after the first dose was given (P = .004) compared with placebo, but did not affect stool form. Adverse events associated with relamorelin included increased appetite, fatigue, and headache. CONCLUSIONS Relamorelin acts in the colon to significantly reduce symptoms of constipation and accelerate CT in patients with chronic constipation, compared with placebo. ClinicalTrial.Gov registration number: NCT01781104.
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Affiliation(s)
- Andres Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota.
| | - Gururaj Kolar
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Johanna Iturrino
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Amy Boldingh
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Duane Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Michael Ryks
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Deborah Rhoten
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
| | - Alan R Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Ernest P Bouras
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Maria I Vazquez-Roque
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida
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13
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Parthasarathy G, Ravi K, Camilleri M, Andrews C, Szarka LA, Low PA, Zinsmeister AR, Bharucha AE. Effect of neostigmine on gastroduodenal motility in patients with suspected gastrointestinal motility disorders. Neurogastroenterol Motil 2015; 27:1736-46. [PMID: 26387781 PMCID: PMC4659742 DOI: 10.1111/nmo.12669] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/11/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acetylcholinesterase inhibitors (ACIs), e.g., neostigmine, are known to increase upper and lower gastrointestinal (GI) motility and are used to treat acute colonic pseudoobstruction. However, their effects on gastroduodenal motility in humans are poorly understood. Our hypotheses were that, in patients with suspected GI motility disorders, neostigmine increases gastric and small intestinal motor activity, and these effects are greater in patients with cardiovagal neuropathy, reflecting denervation sensitivity. METHODS In this open label study, the effects of neostigmine (1 mg intravenously) on gastroduodenal motor activity recorded with manometry were assessed in 28 patients with a suspected GI motility disorder. Cardiovagal function was assessed with the heart rate response to deep breathing and GI transit by scintigraphy. KEY RESULTS The final diagnoses were gastroparesis (6 patients), gastroparesis with intestinal neuropathy (3 patients), intestinal neuropathy or pseudoobstruction (5 patients), functional dyspepsia (6 patients), chronic abdominal pain (3 patients), mechanical small intestinal obstruction (3 patients), and pelvic floor dysfunction (2 patients). Neostigmine increased both antral and intestinal phasic pressure activity (p < 0.001). Neostigmine increased antral and intestinal pressure activity in 81% and 50% of patients with reduced postprandial antral and intestinal contractile responses to meal, respectively. The antroduodenal pressure response to neostigmine was not higher in patients with cardiovagal dysfunction. CONCLUSIONS & INFERENCES Neostigmine increased antral and intestinal motor activity in patients with hypomotility, including intestinal dysmotility. These responses to neostigmine were not greater in patients with cardiovagal dysfunction. The use of longer-acting ACIs for treating antroduodenal dysmotility warrant further study.
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Affiliation(s)
- Gopanandan Parthasarathy
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | - Karthik Ravi
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | | | - Lawrence A. Szarka
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
| | - Phillip A. Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Alan R Zinsmeister
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E. Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
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Bharucha AE, Stroetz R, Feuerhak K, Szarka LA, Zinsmeister AR. A novel technique for bedside anorectal manometry in humans. Neurogastroenterol Motil 2015; 27:1504-8. [PMID: 26227262 PMCID: PMC4584182 DOI: 10.1111/nmo.12636] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/20/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Currently, anorectal manometry (ARM), which is used to diagnose defecatory disorders and identify anal weakness in fecal incontinence (FI) is generally conducted in specialized laboratories. Our aims were to compare anorectal functions measured with high-resolution manometry (HRM) and a novel portable manometry device. METHODS Anal pressures at rest, during squeeze, and simulated evacuation, and rectal sensation were evaluated with portable and HRM in 20 healthy women, 19 women with constipation, and 11 with FI. The relationship between anal pressures measured with portable and HRM was assessed by the concordance correlation coefficient (CCC), Bland Altman test, and paired t-tests. KEY RESULTS Anal pressures at rest (CCC 0.45; 95% CI: 0.29, 0.58) and during squeeze (CCC 0.60; 95% CI: 0.46, 0.72) measured with portable and HRM were correlated and inversely associated with the risk of FI. During simulated evacuation, the CCC for rectal pressure (0.62; 95% CI: 0.43, 0.76) was greater than that for anal pressure (CCC 0.22; 95% CI: 0.04, 0.39) and the rectoanal gradient (CCC 0.22; 95% CI: 0.02, 0.41). Rectal sensory thresholds for first sensation, the desire to defecate, and urgency measured by portable and HRM were also significantly correlated between techniques. For several parameters, differences between portable and HRM were statistically significant and the Bland Altman test was positive. CONCLUSIONS & INFERENCES Anorectal pressures and rectal sensation can be conveniently measured by portable manometry and are significantly correlated with high-resolution manometry.
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Affiliation(s)
- Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Randolph Stroetz
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kelly Feuerhak
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Lawrence A. Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Alan R. Zinsmeister
- Division of Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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15
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Talley NJ, Locke GR, Saito YA, Almazar AE, Bouras EP, Howden CW, Lacy BE, DiBaise JK, Prather CM, Abraham BP, El-Serag HB, Moayyedi P, Herrick LM, Szarka LA, Camilleri M, Hamilton FA, Schleck CD, Tilkes KE, Zinsmeister AR. Effect of Amitriptyline and Escitalopram on Functional Dyspepsia: A Multicenter, Randomized Controlled Study. Gastroenterology 2015; 149:340-9.e2. [PMID: 25921377 PMCID: PMC4516571 DOI: 10.1053/j.gastro.2015.04.020] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 03/13/2015] [Accepted: 04/16/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Antidepressants are frequently prescribed to treat functional dyspepsia (FD), a common disorder characterized by upper abdominal symptoms, including discomfort or postprandial fullness. However, there is little evidence of the efficacy of these drugs in patients with FD. We performed a randomized, double-blind, placebo-controlled trial to evaluate the effects of antidepressant therapy on symptoms, gastric emptying (GE), and meal-induced satiety in patients with FD. METHODS We performed a study at 8 North American sites of patients who met the Rome II criteria for FD and did not have depression or use antidepressants. Patients (n = 292; 44 ± 15 years old, 75% were female, 70% with dysmotility-like FD, and 30% with ulcer-like FD) were randomly assigned to groups given placebo, 50 mg amitriptyline, or 10 mg escitalopram for 10 weeks. The primary end point was adequate relief of FD symptoms for ≥5 weeks of the last 10 weeks (of 12). Secondary end points included GE time, maximum tolerated volume in Nutrient Drink Test, and FD-related quality of life. RESULTS An adequate relief response was reported by 39 subjects given placebo (40%), 51 given amitriptyline (53%), and 37 given escitalopram (38%) (P = .05, after treatment, adjusted for baseline balancing factors including all subjects). Subjects with ulcer-like FD given amitriptyline were >3-fold more likely to report adequate relief than those given placebo (odds ratio = 3.1; 95% confidence interval: 1.1-9.0). Neither amitriptyline nor escitalopram appeared to affect GE or meal-induced satiety after the 10-week period in any group. Subjects with delayed GE were less likely to report adequate relief than subjects with normal GE (odds ratio = 0.4; 95% confidence interval: 0.2-0.8). Both antidepressants improved overall quality of life. CONCLUSIONS Amitriptyline, but not escitalopram, appears to benefit some patients with FD, particularly those with ulcer-like (painful) FD. Patients with delayed GE do not respond to these drugs. ClinicalTrials.gov ID: NCT00248651.
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Affiliation(s)
- Nicholas J. Talley
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN,Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | | | - Yuri A. Saito
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ann E. Almazar
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Brian E. Lacy
- Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John K. DiBaise
- Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ
| | | | - Bincy P. Abraham
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
| | - Hashem B. El-Serag
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
| | - Paul Moayyedi
- Gastroenterology, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | - Cathy D. Schleck
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Flanagan EP, Saito YA, Lennon VA, McKeon A, Fealey RD, Szarka LA, Murray JA, Foxx-Orenstein AE, Fox JC, Pittock SJ. Immunotherapy trial as diagnostic test in evaluating patients with presumed autoimmune gastrointestinal dysmotility. Neurogastroenterol Motil 2014; 26:1285-97. [PMID: 25039328 PMCID: PMC4149849 DOI: 10.1111/nmo.12391] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/07/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic gastrointestinal dysmotility greatly impacts the quality of life. Treatment options are limited and generally symptomatic. Neural autoimmunity is an under-recognized etiology. We evaluated immunotherapy as an aid to diagnosing autoimmune gastrointestinal dysmotility (AGID). METHODS Twenty-three subjects evaluated at the Mayo Clinic for suspected AGID (August 2006-February 2014) fulfilled the following criteria: (1) prominent symptoms of gastrointestinal dysmotility with abnormalities on scintigraphy-manometry; (2) serological evidence or personal/family history of autoimmune disease; (3) treated by immunotherapy on a trial basis, 6-12 weeks (intravenous immune globulin, 16; or methylprednisolone, 5; or both, 2). Response was defined subjectively (symptomatic improvement) and objectively (gastrointestinal scintigraphy/manometry studies). KEY RESULTS Symptoms at presentation: constipation, 18/23; nausea or vomiting, 18/23; weight loss, 17/23; bloating, 13/23; and early satiety, 4/23. Thirteen patients had personal/family history of autoimmunity. Sixteen had neural autoantibodies and 19 had extra-intestinal autonomic testing abnormalities. Cancer was detected in three patients. Preimmunotherapy scintigraphy revealed slowed transit (19/21 evaluated; gastric, 11; small bowel, 12; colonic, 11); manometry studies were abnormal in 7/8. Postimmunotherapy, 17 (74%) had improvement (both symptomatic and scintigraphic, five; symptomatic alone, eight; scintigraphic alone, four). Nine responders re-evaluated had scintigraphic evidence of improvement. The majority of responders who were re-evaluated had improvement in autonomic testing (six of seven) or manometry (two of two). CONCLUSIONS & INFERENCES This proof of principle study illustrates the importance of considering an autoimmune basis for idiopathic gastrointestinal dysmotility and supports the utility of a diagnostic trial of immunotherapy.
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Affiliation(s)
- E P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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17
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Rajan E, Gostout CJ, Bonin EA, Moran EA, Locke GR, Szarka LA, Talley NJ, Deters JL, Miller CA, Knipschield MA, Lurken MS, Stoltz GJ, Bernard CE, Grover M, Farrugia G. Endoscopic full-thickness biopsy of the gastric wall with defect closure by using an endoscopic suturing device: survival porcine study. Gastrointest Endosc 2012; 76:1014-9. [PMID: 23078926 PMCID: PMC3666864 DOI: 10.1016/j.gie.2012.07.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 07/06/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The pathogenesis of several common gastric motility diseases and functional GI disorders remains essentially unexplained. Gastric wall biopsies that include the muscularis propria to evaluate the enteric nervous system, interstitial cells of Cajal, and immune cells can provide important insights for our understanding of the etiology of these disorders. OBJECTIVES To determine the technical feasibility, reproducibility, and safety of performing a full-thickness gastric biopsy (FTGB) by using a submucosal endoscopy with mucosal flap (SEMF) technique; the technical feasibility, reproducibility, and safety of tissue closure by using an endoscopic suturing device; the ability to identify myenteric ganglia in resected specimens; and the long-term safety. DESIGN Single center, preclinical survival study. SETTING Animal research laboratory, developmental endoscopy unit. SUBJECTS Twelve domestic pigs. INTERVENTIONS Animals underwent an SEMF procedure with gastric muscularis propria resection. The resultant offset mucosal entry site was closed by using an endoscopic suturing device. Animals were kept alive for 2 weeks. MAIN OUTCOME MEASUREMENTS The technical feasibility, reproducibility, and safety of the procedure; the clinical course of the animals; the histological and immunochemical evaluation of the resected specimen to determine whether myenteric ganglia were present in the sample. RESULTS FTGB was performed by using the SEMF technique in all 12 animals. The offset mucosal entry site was successfully closed by using the suturing device in all animals. The mean resected tissue specimen size was 11 mm. Mean total procedure time was 61 minutes with 2 to 4 interrupted sutures placed per animal. Histology showed muscularis propria and serosa, confirming full-thickness resections in all animals. Myenteric ganglia were visualized in 11 of 12 animals. The clinical course was uneventful. Repeat endoscopy and necropsy at 2 weeks showed absence of ulceration at both the mucosal entry sites and overlying the more distal muscularis propria resection sites. There was complete healing of the serosa in all animals with minimal single-band adhesions in 5 of 12 animals. Retained sutures were present in 10 of 12 animals. LIMITATIONS Animal experiment. CONCLUSIONS FTGB by using the SEMF technique and an endoscopic suturing device is technically feasible, reproducible, and safe. Larger tissue specimens will allow improved analysis of multiple cell types.
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Affiliation(s)
| | | | | | | | - GR Locke
- Developmental Endoscopy Unit and Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - LA Szarka
- Developmental Endoscopy Unit and Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | | | | | | | | | | | - GJ Stoltz
- Developmental Endoscopy Unit and Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - CE Bernard
- Developmental Endoscopy Unit and Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - M Grover
- Developmental Endoscopy Unit and Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - G Farrugia
- Developmental Endoscopy Unit and Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
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Abstract
Patients presenting with megacolon and megarectum require extensive specialized testing to distinguish underlying Hirschsprung's disease from other secondary causes. Diagnostic testing and long-term treatment are best initiated after disimpaction has been achieved, by large-volume tap water enemas and/or oral colonic lavage with polyethylene glycol. With intensive treatment (including biofeedback if pelvic floor dysfunction is present), at lease one half of patients can avoid surgery. Maintenance therapy relies on daily use of osmotic laxatives. Stimulant laxatives are used intermittently as rescue treatments if there has not been a satisfactory bowel movement in 3 days. Patients with idiopathic megacolon or megarectum may require surgery if they have refractory symptoms. Depending on age, pelvic floor, and anal sphincter function, patients who have isolated megacolon can be treated with either subtotal colectomy with ileorectostomy or diverting loop ileostomy. Patients with isolated megarectum can be treated with either proctectomy and coloanal anastomosis or vertical reduction rectoplasty. Patients who have combined megacolon and megarectum can be offered diverting loop ileostomy or, if pelvic floor function is normal and they wish to avoid stoma, total proctocolectomy with ileal pouch-anal anastomosis.
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Affiliation(s)
- Lawrence A Szarka
- Colon and Rectal Surgery, Mayo Clinic College of Medicine and Mayo Foundation, 200 First Street SW, Gonda 9-S, Rochester, MN 55905, USA.
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Abstract
Transit assessment of the small intestine and colon is relevant in the study of physiology, pathophysiology, and pharmacodynamics, and there is increasing use of small-bowel and colonic transit measurements in clinical practice as well. The main methods that are applied in clinical practice are substrate-hydrogen breath tests for small-bowel transit and radiopaque markers for colonic transit. Over the past 2-3 decades, scintigraphy has become the preferred standard in research studies, particularly for studies of pathophysiology and pharmacodynamics. New approaches include experimental stable isotope measurement of orocecal transit and the recently approved method using a wireless motility capsule that is validated as an accurate measurement of small-bowel and colonic transit.
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Affiliation(s)
- Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Revicki DA, Camilleri M, Kuo B, Szarka LA, McCormack J, Parkman HP. Evaluating symptom outcomes in gastroparesis clinical trials: validity and responsiveness of the Gastroparesis Cardinal Symptom Index-Daily Diary (GCSI-DD). Neurogastroenterol Motil 2012; 24:456-63, e215-6. [PMID: 22284754 DOI: 10.1111/j.1365-2982.2012.01879.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patient-reported symptom scales are needed to evaluate treatments for gastroparesis. The Gastroparesis Cardinal Symptom Index-Daily Diary (GCSI-DD) was developed to assess daily symptoms of gastroparesis. This study evaluated the validity and responsiveness of the GCSI-DD in patients with gastroparesis. METHODS Symptomatic patients were started with a new treatment for gastroparesis. Patients completed the GCSI-DD each evening during a baseline week and for 8 weeks of treatment. Responders were defined based on patient and clinician global rating of change. Minimal important differences (MID) were estimated based on baseline to 4 week changes in symptoms scores for small improvements. KEY RESULTS Of 69 patients participating, 46 had idiopathic, 19 diabetic, and four postfundoplication gastroparesis. Excellent test-retest reliability was seen for GCSI-DD scores, and there were significant correlations between GCSI-DD scores and clinician ratings of symptom severity. Responders to treatment reported improvements in nausea [effect size (ES) = 0.42, P < 0.001], postprandial fullness, ES = 0.83, P < 0.001), bloating (ES = 0.34, P < 0.001), early satiety (ES = 0.53, P < 0.001), but lower responses for upper abdominal pain (ES = 0.29), and vomiting (ES = 0.22; P = 0.119). MIDs were 0.55 for nausea, 0.97 for excessive fullness, 0.63 for bloating, 0.77 for postprandial fullness, and 0.30 for abdominal pain. A composite score of four symptoms (Composite-1; nausea, bloating, excessive fullness, postprandial fullness) had ES of 0.61 and MID of 0.73. Composite-2 score (nausea, early satiety, bloating, abdominal pain) had a lower ES of 0.47. CONCLUSIONS & INFERENCES Symptoms of early satiety, nausea, postprandial fullness, and bloating were responsive to treatment for gastroparesis. A composite of these symptoms also demonstrates validity and responsiveness to treatment for gastroparesis, and may represent an acceptable endpoint for evaluating the effectiveness of medical treatments in clinical trials for gastroparesis.
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Affiliation(s)
- D A Revicki
- United BioSource Corporation, Bethesda, MD 20814, USA.
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Affiliation(s)
- Seth Sweetser
- Division of Gastroenterology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Wong BS, Camilleri M, Busciglio I, Carlson P, Szarka LA, Burton D, Zinsmeister AR. Pharmacogenetic trial of a cannabinoid agonist shows reduced fasting colonic motility in patients with nonconstipated irritable bowel syndrome. Gastroenterology 2011; 141:1638-47.e1-7. [PMID: 21803011 PMCID: PMC3202649 DOI: 10.1053/j.gastro.2011.07.036] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 07/01/2011] [Accepted: 07/19/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Cannabinoid receptors are located on cholinergic neurons. Genetic variants that affect endocannabinoid metabolism are associated with colonic transit in patients with irritable bowel syndrome (IBS) with diarrhea. We compared the effects of dronabinol, a nonselective agonist of the cannabinoid receptor, with those of placebo on colonic motility and sensation in patients with IBS, and examined the effects of IBS subtype and specific genetic variants in cannabinoid mechanisms. METHODS Seventy-five individuals with IBS (35 with IBS with constipation, 35 with IBS with diarrhea, and with 5 IBS alternating) were randomly assigned to groups that were given 1 dose of placebo or 2.5 mg or 5.0 mg dronabinol. We assessed left colonic compliance, motility index (MI), tone, and sensation during fasting and after a meal. We analyzed the single nucleotide polymorphisms CNR1 rs806378, fatty acid amide hydrolase (FAAH) rs324420, and MGLL rs4881. RESULTS In all patients, dronabinol decreased fasting proximal left colonic MI compared with placebo (overall P = .05; for 5 mg dronabinol, P = .046), decreased fasting distal left colonic MI (overall P = .08; for 5 mg, P = .13), and increased colonic compliance (P = .058). The effects of dronabinol were greatest in patients with IBS with diarrhea or IBS alternating (proximal colonic MI, overall P = .022; compliance, overall P = .03). Dronabinol did not alter sensation or tone. CNR1 rs806378 (CC vs CT/TT) appeared to affect fasting proximal MI in all patients with IBS (P = .075). Dronabinol affected fasting distal MI in patients, regardless of FAAH rs324420 variant (CA/AA vs CC) (P = .046); the greatest effects were observed among IBS with constipation patients with the FAAH CC variant (P = .045). Dronabinol affected fasting proximal MI in patients with IBS with diarrhea or alternating with the variant FAAH CA/AA (P = .013). CONCLUSIONS In patients with IBS with diarrhea or alternating, dronabinol reduces fasting colonic motility; FAAH and CNR1 variants could influence the effects of this drug on colonic motility.
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Affiliation(s)
- Banny S. Wong
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
| | - Irene Busciglio
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
| | - Paula Carlson
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
| | - Lawrence A. Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
| | - Duane Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
| | - Alan R. Zinsmeister
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics College of Medicine, Mayo Clinic Rochester, Minnesota
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Parkman HP, Camilleri M, Farrugia G, McCallum RW, Bharucha AE, Mayer EA, Tack JF, Spiller R, Horowitz M, Vinik AI, Galligan JJ, Pasricha PJ, Kuo B, Szarka LA, Marciani L, Jones K, Parrish CR, Sandroni P, Abell T, Ordog T, Hasler W, Koch KL, Sanders K, Norton NJ, Hamilton F. Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting. Neurogastroenterol Motil 2010; 22:113-33. [PMID: 20003077 PMCID: PMC2892213 DOI: 10.1111/j.1365-2982.2009.01434.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite the relatively high prevalence of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders. PURPOSE This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.
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Affiliation(s)
- H P Parkman
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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24
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Abstract
Gastroparesis and other types of gastric dysfunction result in substantial morbidity in diabetes patients. The pathophysiology of these disorders is incompletely understood. This article reviews techniques applicable to the assessment of gastric function in diabetes patients, including the measurement of emptying, accommodation, and contractility. Available treatment options are also reviewed, including novel yet unapproved serotonin 5-HT(4) agonist pharmacological treatments, as well as the role of endoscopic, surgical, and device treatments of gastroparesis.
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Affiliation(s)
- Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), College of Medicine, Mayo Clinic, Rochester, Minnesota
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25
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Malhotra A, Szarka LA. Chronic idiopathic intestinal pseudo-obstruction: a case report and discussion. Conn Med 2009; 73:457-460. [PMID: 19777978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Ashish Malhotra
- Division of Gastroenterology and Hepatolog, Carl T Hayden VA Medical Center, Phoenix, AZ 85020, USA
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Affiliation(s)
- Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Breath tests (BT) using 13C-substrates have been proposed for the measurement of gastric emptying (GE). The mathematical analysis of the breath 13CO2 excretion that most accurately predicts GE t(1/2) from simultaneous scintigraphy is unresolved. To compare five mathematical methods to estimate GE t(1/2) by BT with t(1/2) from simultaneous scintigraphy. Data acquired from a dual-labelled solid-liquid meal containing 99mTc sulphur colloid and 13C-Spirulina platensis from 57 healthy volunteers were used to compare four mathematical methods reported in the literature [Ghoos method; generalized linear regression (Viramontes); linear regression (Szarka); Wagner-Nelson method] and the total cumulative breath 13CO2 excretion with > or =12 breath samples collected over at least 4 h. The concordance correlation coefficient (CCC) for the t(1/2) results obtained with each method using BT data was compared with the results obtained with scintigraphy. The linear regression and generalized linear regression methods used five samples at 45, 90, 120, 150 and 180 min. All methods, except for the Wagner-Nelson method, resulted in mean GE t(1/2) that approximated t(1/2) obtained with scintigraphy. The highest CCC was observed with the linear regression method. Simple cumulative excretion of breath 13CO2 provides a better CCC than the Ghoos method. The linear regression and generalized linear regression methods (which also require relatively few breath samples) provide the most accurate analyses of breath 13CO2 excretion in stable isotope GEBT.
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Affiliation(s)
- Suwebatu T. Odunsi
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
| | - Lawrence A. Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
| | - Alan R. Zinsmeister
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
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28
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Jung HK, Choung RS, Locke GR, Schleck CD, Zinsmeister AR, Szarka LA, Mullan B, Talley NJ. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006. Gastroenterology 2009; 136:1225-33. [PMID: 19249393 PMCID: PMC2705939 DOI: 10.1053/j.gastro.2008.12.047] [Citation(s) in RCA: 361] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 12/12/2008] [Accepted: 12/18/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The epidemiology of gastroparesis is unknown. We aimed to determine the incidence, prevalence, and outcome of gastroparesis in the community. METHODS Using the Rochester Epidemiology Project, a medical records linkage system in Olmsted County, Minnesota, we identified county residents with potential gastroparesis. The complete medical records were reviewed by a gastroenterologist. Three diagnostic definitions were used: (1) definite gastroparesis, delayed gastric emptying by standard scintigraphy and typical symptoms for more than 3 months; (2) probable gastroparesis, typical symptoms and food retention on endoscopy or upper gastrointestinal study; (3) possible gastroparesis, typical symptoms alone or delayed gastric emptying by scintigraphy without gastrointestinal symptoms. Poisson regression was used to assess the association of incidence rates with age, sex, and calendar period. RESULTS Among 3604 potential cases of gastroparesis, 83 met diagnostic criteria for definite gastroparesis, 127 definite plus probable gastroparesis, and 222 any of the 3 definitions of gastroparesis. The age-adjusted (to the 2000 US white population) incidence per 100,000 person-years of definite gastroparesis for the years 1996-2006 was 2.4 (95% confidence interval [CI], 1.2-3.8) for men and 9.8 (95% CI, 7.5-12.1) for women. The age-adjusted prevalence of definite gastroparesis per 100,000 persons on January 1, 2007, was 9.6 (95% CI, 1.8-17.4) for men and 37.8 (95% CI, 23.3-52.4) for women. Overall survival was significantly lower than the age- and sex-specific expected survival computed from the Minnesota white population (P<.05). CONCLUSIONS Gastroparesis is an uncommon condition in the community but is associated with a poor outcome.
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Affiliation(s)
- Hye-kyung Jung
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Rok Seon Choung
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - G. Richard Locke
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Cathy D. Schleck
- Department of Health Sciences Research and Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Alan R. Zinsmeister
- Department of Health Sciences Research and Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Lawrence A. Szarka
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Brian Mullan
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas J. Talley
- Enteric Neuroscience Program and Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, Department OF Medicine, Mayo Clinic Florida
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Abstract
There is an array of tests available to measure gastric motility. Some tests measure end points, such as gastric emptying, that result from several different functions, whereas other tests are more specific and test only a single parameter, such as contractility. This article reviews the tests most commonly available in practice and research to evaluate in vivo the gastric functions of emptying, accommodation, contractility, and myoelectrical activity. The rationale for testing, the relative strengths and weaknesses of each test, and technical details are summarized. We also briefly indicate the applications and validations of the tests for use in experimental animal studies.
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Affiliation(s)
- Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Charlton 8-110, 200 First St. S.W., Rochester, MN 55905, USA
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Sweetser S, Busciglio IA, Camilleri M, Bharucha AE, Szarka LA, Papathanasopoulos A, Burton DD, Eckert DJ, Zinsmeister AR. Effect of a chloride channel activator, lubiprostone, on colonic sensory and motor functions in healthy subjects. Am J Physiol Gastrointest Liver Physiol 2009; 296:G295-301. [PMID: 19033530 PMCID: PMC2643920 DOI: 10.1152/ajpgi.90558.2008] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lubiprostone, a bicyclic fatty acid chloride channel activator, is efficacious in treatment of chronic constipation and constipation-predominant irritable bowel syndrome. The study aim was to compare effects of lubiprostone and placebo on colonic sensory and motor functions in humans. In double-blind, randomized fashion, 60 healthy adults received three oral doses of placebo or 24 microg lubiprostone per day in a parallel-group, placebo-controlled trial. A barostat-manometry tube was placed in the left colon by flexible sigmoidoscopy and fluoroscopy. We measured treatment effects on colonic sensation and motility with validated methods, with the following end points: colonic compliance, fasting and postprandial tone and motility indexes, pain thresholds, and sensory ratings to distensions. Among participants receiving lubiprostone or placebo, 26 of 30 and 28 of 30, respectively, completed the study. There were no overall effects of lubiprostone on compliance, fasting tone, motility indexes, or sensation. However, there was a treatment-by-sex interaction effect for compliance (P = 0.02), with lubiprostone inducing decreased fasting compliance in women (P = 0.06) and an overall decreased colonic tone contraction after a standard meal relative to fasting tone (P = 0.014), with greater effect in women (P < 0.01). Numerical differences of first sensation and pain thresholds (P = 0.11 in women) in the two groups were not significant. We concluded that oral lubiprostone 24 microg does not increase colonic motor function. The findings of decreased colonic compliance and decreased postprandial colonic tone in women suggest that motor effects are unlikely to cause accelerated colonic transit with lubiprostone, although they may facilitate laxation. Effects of lubiprostone on sensitivity deserve further study.
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Affiliation(s)
- Seth Sweetser
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Irene A. Busciglio
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Lawrence A. Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Athanasios Papathanasopoulos
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Duane D. Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deborah J. Eckert
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alan R. Zinsmeister
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER) Group, College of Medicine, Mayo Clinic, Rochester, Minnesota
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31
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Rajan E, Gostout CJ, Lurken MS, Talley NJ, Locke GR, Szarka LA, Sumiyama K, Bakken TA, Stoltz GJ, Knipschield MA, Farrugia G. Endoscopic "no hole" full-thickness biopsy of the stomach to detect myenteric ganglia. Gastrointest Endosc 2008; 68:301-7. [PMID: 18262183 PMCID: PMC2814422 DOI: 10.1016/j.gie.2007.10.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 10/02/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The etiology of several common gastric motility diseases remains largely unknown. Gastric wall biopsy specimens that include the muscularis propria to evaluate the enteric nervous system, interstitial cells of Cajal, and related cells are essential to promote our understanding of the pathophysiologic mechanisms. On the basis of our previous work, a double EMR technique provided sufficient tissue to identify myenteric ganglia. A serious limitation to the technique was the resultant gastric wall perforation after tissue resection. The optimal procedure would seal the gastric wall defect before tissue resection, eliminating the risk of peritonitis. OBJECTIVES The aims of this study were to (1) determine the technical feasibility and reproducibility of a full-thickness gastric biopsy by use of a novel double EMR technique without creating a perforation ("no hole") and to (2) determine safety of the procedure. DESIGN AND INTERVENTIONS Preclinical study of 6 pigs. Each animal underwent a "no hole" double EMR survival procedure. To prevent perforation, detachable endoloops and prototype T-tag tissue anchors were placed before resection. At 2 weeks repeat endoscopy was performed followed by necropsy. MAIN OUTCOME MEASUREMENTS Hematoxylin-eosin staining was used to determine which muscle layers were included in the resected specimen, and an antibody to neuronal nitric oxide synthase was used to visualize myenteric ganglia in the sample. Technical feasibility, reproducibility, and safety of the procedure were evaluated. RESULTS Full-thickness gastric biopsy specimens were obtained from all animals without overt perforation. There were no procedural complications. Histologic examination showed muscularis propria with all layers of muscle present, and immunochemical studies demonstrated myenteric ganglia in all tissue samples. Four animals had an uneventful clinical course, and repeat endoscopy at week 2 showed ulceration with stellate fibrosis. Necropsy showed mild localized adhesions. Two animals were killed at days 3 and 6, respectively, because of suspected peritonitis. At necropsy, delayed perforations at the resection sites were noted with displaced endoloops and tissue anchors. CONCLUSION This study explored the concept of obtaining deep muscle wall biopsy specimens with use of a unique approach of resection without perforation. The novel "no hole" double EMR technique was technically feasible and reproducible with sufficient tissue obtained to identify myenteric ganglia. However, there was a high delayed perforation rate associated with displaced endoloops and tissue anchors. On the basis of this early experience, improved safety data may be anticipated with future studies using improved tissue closure devices.
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Affiliation(s)
- Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Developmental Endoscopy Unit, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Szarka LA, Camilleri M, Vella A, Burton D, Baxter K, Simonson J, Zinsmeister AR. A stable isotope breath test with a standard meal for abnormal gastric emptying of solids in the clinic and in research. Clin Gastroenterol Hepatol 2008; 6:635-643.e1. [PMID: 18406670 PMCID: PMC3739971 DOI: 10.1016/j.cgh.2008.01.009] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to validate a [13C]-Spirulina platensis gastric emptying (GE) breath test (GEBT) with a standardized meal. METHODS Thirty-eight healthy volunteers and 129 patients with clinically suspected delayed GE underwent measurements at 45, 90, 120, 150, 180, and 240 minutes after a 238 kcal meal labeled test with 100 mg [13C]-S platensis and 0.5 mCi 99mTc. We established normal ranges for scintigraphy with this test meal, intraindividual and interindividual coefficients of variation (COVs), and the ability of the [13C] GEBT breath percent dose excreted *1000 values to predict scintigraphic half-life and to categorize GE as delayed, normal, or accelerated. RESULTS In health, the 10th and 90th percentiles of half-life for scintigraphic GE with this meal were 52 and 86 minutes; intraindividual COVs for scintigraphy and the GEBT were, respectively, 31% and 27% at 45 minutes, 17% and 21% at 90 minutes, 13% and 16% at 120 minutes, 10% and 13% at 150 minutes, and 8% and 12% at 180 minutes. Interindividual COVs at each time for the [13C] GEBT and scintigraphy were typically approximately 1%-4% lower than intraindividual COVs. Individual breath samples at 45, 150, and 180 minutes predicted GE category; at 80% specificity, 45- and 180-minute samples combined were 93% sensitive to identify accelerated GE, and 150- and 180-minute combined were 89% sensitive for delayed GE. CONCLUSIONS [13C]-S platensis GEBT is as reproducible as scintigraphy; imprecision with both tests reflects physiologic variation. With 4 breath samples, this method with an off-the-shelf meal is valid to assess GE in clinic and in research.
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Affiliation(s)
| | | | | | | | | | | | - Alan R. Zinsmeister
- Department of Health Sciences Research, Division of Biostatistics College of Medicine, Mayo Clinic, Rochester, MN 55905
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Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, McCallum RW, Nowak T, Nusynowitz ML, Parkman HP, Shreve P, Szarka LA, Snape WJ, Ziessman HA. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Am J Gastroenterol 2008; 103:753-63. [PMID: 18028513 DOI: 10.1111/j.1572-0241.2007.01636.x] [Citation(s) in RCA: 410] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This consensus statement from the members of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine recommends a standardized method for measuring gastric emptying (GE) by scintigraphy. A low-fat, egg-white meal with imaging at 0, 1, 2, and 4 h after meal ingestion, as described by a published multicenter protocol, provides standardized information about normal and delayed GE. Adoption of this standardized protocol will resolve the lack of uniformity of testing, add reliability and credibility to the results, and improve the clinical utility of the GE test.
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Affiliation(s)
- Thomas L Abell
- Gastroenterology, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, McCallum RW, Nowak T, Nusynowitz ML, Parkman HP, Shreve P, Szarka LA, Snape WJ, Ziessman HA. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. J Nucl Med Technol 2008. [PMID: 18287197 DOI: 10.2967/jnmt.107.04811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
This consensus statement from the members of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine recommends a standardized method for measuring gastric emptying (GE) by scintigraphy. A low-fat, egg-white meal with imaging at 0, 1, 2, and 4 h after meal ingestion, as described by a published multicenter protocol, provides standardized information about normal and delayed GE. Adoption of this standardized protocol will resolve the lack of uniformity of testing, add reliability and credibility to the results, and improve the clinical utility of the GE test.
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Affiliation(s)
- Thomas L Abell
- Gastroenterology, University of Mississippi Medical Center, Jackson, MS, USA
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35
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Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, McCallum RW, Nowak T, Nusynowitz ML, Parkman HP, Shreve P, Szarka LA, Snape WJ, Ziessman HA. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. J Nucl Med Technol 2008; 36:44-54. [PMID: 18287197 DOI: 10.2967/jnmt.107.048116] [Citation(s) in RCA: 244] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
This consensus statement from the members of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine recommends a standardized method for measuring gastric emptying (GE) by scintigraphy. A low-fat, egg-white meal with imaging at 0, 1, 2, and 4 h after meal ingestion, as described by a published multicenter protocol, provides standardized information about normal and delayed GE. Adoption of this standardized protocol will resolve the lack of uniformity of testing, add reliability and credibility to the results, and improve the clinical utility of the GE test.
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Affiliation(s)
- Thomas L Abell
- Gastroenterology, University of Mississippi Medical Center, Jackson, MS, USA
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36
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Rajan E, Gostout CJ, Lurken MS, Talley NJ, Locke GR, Szarka LA, Levy MJ, Sumiyama K, de la Mora-Levy JG, Bakken TA, Stoltz GJ, Knipschield MA, Farrugia G. Evaluation of endoscopic approaches for deep gastric-muscle-wall biopsies: what works? Gastrointest Endosc 2008; 67:297-303. [PMID: 18028922 DOI: 10.1016/j.gie.2007.06.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Accepted: 06/07/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND A major barrier to furthering our understanding of the pathophysiology of neuromuscular GI diseases, including functional GI disorders, is the inability to obtain deep gastric-wall biopsy specimens that include both layers of the muscularis propria, which allows evaluation of specific cell types, including myenteric ganglia. OBJECTIVES The aims of this preclinical study were to (1) evaluate different endoscopic approaches for obtaining deep gastric-muscle-wall biopsy specimens and (2) determine if myenteric ganglia were present in the tissue samples. DESIGN AND INTERVENTIONS This was a preclinical acute study by using a pig model. Multiple samples were obtained from 4 pigs. The endoscopic techniques evaluated were (1) EUS-guided tru-cut biopsy of the gastric wall, (2) jumbo biopsy of the post-EMR site, (3) jumbo biopsy of the gastrotomy margin, (4) serosal-side biopsy through a gastrotomy, and (5) double-EMR resection. MAIN OUTCOME MEASUREMENTS Resected tissue was submitted for histology to determine which wall layers were included in the resected specimen. Hematoxylin and eosin staining was used to determine which muscle layers were biopsied, and an antibody to protein gene product 9.5 was used to determine if myenteric ganglia were present in the sample. RESULTS Seventy-two tissue samples were obtained: EUS-guided tru-cut biopsy (n=16), jumbo biopsy of the post-EMR site (n=16), jumbo biopsy of the gastrotomy (n=16), serosal-side biopsy (n=16), and double-EMR resection (n=8). Only the double-EMR resection tissues showed the presence of longitudinal muscle, indicating the presence of both muscle layers and the myenteric plexus. Immunofluorescence studies demonstrated the presence of myenteric ganglia only in the double-EMR tissues and in none of the other gastric samples. No adjacent organs were included in the resection. CONCLUSIONS The double-EMR technique was the only studied technique that resulted in a deep gastric-wall sample and provided sufficient tissue to evaluate both muscle layers and the intermuscular layer that contain myenteric ganglia. Further studies are needed to verify the efficacy and to assess the safety of this approach.
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Affiliation(s)
- Elizabeth Rajan
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Szarka LA, Camilleri M, Burton D, Fox JC, McKinzie S, Stanislav T, Simonson J, Sullivan N, Zinsmeister AR. Efficacy of on-demand asimadoline, a peripheral kappa-opioid agonist, in females with irritable bowel syndrome. Clin Gastroenterol Hepatol 2007; 5:1268-75. [PMID: 17900994 PMCID: PMC2128734 DOI: 10.1016/j.cgh.2007.07.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In experimental animal models of irritable bowel syndrome (IBS) and human studies, peripheral kappa opioid agonists have been shown to decrease sensation to colonic distention. The aim of this study was to compare the effects of the kappa opioid agonist, asimadoline, and placebo on episodes of abdominal pain in patients with IBS. METHODS After a 2-week run-in period, 100 patients with IBS were randomized (3:2 ratio) to receive asimadoline, up to 1 mg 4 times daily, or placebo for 4 weeks in a double-blind study. Pain was scored by daily diary using a 100-mm visual analogue scale. During pain episodes, patients recorded the pain severity, took study medication, and recorded their pain score 2 hours later. The primary end point was the average reduction in pain severity 2 hours after treatment. RESULTS The average pain reduction 2 hours posttreatment was not significantly different between the groups. Post hoc analyses suggest asimadoline was effective in mixed IBS (P = .003, unadjusted), but may be worse in diarrhea-predominant IBS (P = .065 unadjusted). The anxiety score was reduced modestly by asimadoline (P = .053). No significant adverse effects were noted. CONCLUSIONS An on-demand dosing schedule of asimadoline was not effective in reducing severity of abdominal pain in IBS. Further studies in visceral pain and IBS appear warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alan R. Zinsmeister
- Corresponding author: Michael Camilleri, M.D., Mayo Clinic, Charlton 8-110, 200 First Street S.W., Rochester, MN 55905,
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Foxx-Orenstein AE, Camilleri M, Szarka LA, McKinzie S, Burton D, Thomforde G, Baxter K, Zinsmeister AR. Does co-administration of a non-selective opiate antagonist enhance acceleration of transit by a 5-HT4 agonist in constipation-predominant irritable bowel syndrome? A randomized controlled trial. Neurogastroenterol Motil 2007; 19:821-30. [PMID: 17539894 DOI: 10.1111/j.1365-2982.2007.00944.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Opioid neurons exhibit tonic restraint on intestinal motility; opioid antagonists stimulate peristalsis and increase transit. In vitro, 5-hydroxytryptamine (5-HT4) agonists combined with selective opioid antagonists significantly increased colonic propulsion relative to a 5-HT4 agonist alone. We hypothesized that the combination of 5-HT4 agonist and non-selective opioid antagonist enhances intestinal transit more than either treatment alone in female constipation-predominant irritable bowel syndrome (C-IBS) patients. Our aim was to examine the effect of tegaserod 6 mg b.i.d. alone and combined with naltrexone 50 mg on intestinal transit and stool characteristics in females with C-IBS. Forty-eight patients were randomized to tegaserod alone, naltrexone alone or in combination with tegaserod or placebo for 6 days. Small bowel, ascending colon half-life (in pharmacokinetics) (t1/2), and colonic geometric centre (8, 24, 48 h) were assessed by scintigraphy. Tegaserod increased small bowel (P < 0.01) and colon transit (P < 0.01). Naltrexone did not accelerate colonic transit relative to placebo. Combination treatment did not significantly accelerate transit relative to tegaserod alone. Tegaserod and tegaserod with naltrexone resulted in looser stool form (P < 0.01). In female C-IBS patients, tegaserod accelerates small bowel and colon transit and contributed to looser stool consistency. Use of naltrexone, 50 mg, does not support the hypothesis that combination of 5-HT4 agonist and non-selective opioid antagonist enhances intestinal transit.
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Affiliation(s)
- A E Foxx-Orenstein
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Szarka LA, Foxx-Orenstein AE. Evaluation and treatment of obesity. Clin Gastroenterol Hepatol 2006; 4:677-83. [PMID: 16632410 DOI: 10.1016/j.cgh.2006.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Lawrence A Szarka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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40
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Delgado-Aros S, Chial HJ, Camilleri M, Szarka LA, Weber FT, Jacob J, Ferber I, McKinzie S, Burton DD, Zinsmeister AR. Effects of a kappa-opioid agonist, asimadoline, on satiation and GI motor and sensory functions in humans. Am J Physiol Gastrointest Liver Physiol 2003; 284:G558-66. [PMID: 12631557 DOI: 10.1152/ajpgi.00360.2002] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To compare the effects of the kappa-opioid agonist asimadoline and placebo on visceral sensation and gastrointestinal (GI) motor functions in humans, 91 healthy participants were randomized in a double-blind fashion to 0.15, 0.5, or 1.5 mg of asimadoline or placebo orally twice a day for 9 days. We assessed satiation (nutrient drink test), colonic compliance, tone, perception of colonic distension (barostat), and whole gut transit (scintigraphy). Treatment effect was assessed by analysis of covariance. Asimadoline increased nutrient drink intake (P = 0.03). Asimadoline decreased colonic tone during fasting (P = 0.03) without affecting postprandial colonic contraction, compliance, or transit. Gas scores in response to colonic distension were decreased with 0.5 mg of asimadoline at low levels (8 mmHg above operating pressure) of distension (P = 0.04) but not at higher levels of distension. Asimadoline at 1.5 mg increased gas scores at 16 mmHg of distension (P = 0.03) and pain scores at distensions of 8 and 16 mmHg (P = 0.003 and 0.03, respectively) but not at higher levels of distension. Further studies of this compound in diseases with altered satiation or visceral sensation are warranted.
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Affiliation(s)
- Silvia Delgado-Aros
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota 55905, USA
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Vella A, Lee JS, Camilleri M, Szarka LA, Burton DD, Zinsmeister AR, Rizza RA, Klein PD. Effects of pramlintide, an amylin analogue, on gastric emptying in type 1 and 2 diabetes mellitus. Neurogastroenterol Motil 2002; 14:123-31. [PMID: 11975712 DOI: 10.1046/j.1365-2982.2002.00311.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pramlintide delays gastric emptying, possibly by a centrally mediated mechanism. Our aim was to determine whether the effects of pramlintide on gastric emptying differ in people with type 1 or type 2 diabetes who had no history of complications. Using a randomized, three-period, two-dose, crossover design, we studied the effects of 0, 30, or 60 microg t.i.d. pramlintide subcutaneously for 5 days each in six type 1 and six type 2 diabetic subjects. Gastric emptying of solids was measured by 13C-Spirulina breath test. Plasma pancreatic polypeptide (HPP) response to the test meal was also measured. Relative to placebo [t 50% 91 +/- 6 min (means +/- SEM)], pramlintide equally delayed gastric emptying following 30 or 60 microg t.i.d. (268 +/- 37 min, 329 +/- 49 min, respectively; P < 0.01]. Postprandial HPP levels were lower in response to 30 and 60 microg pramlintide compared to placebo. There were no significant differences in the effects on gastric emptying or HPP levels between type 1 and type 2 diabetic subjects. Pramlintide delays gastric emptying in diabetes unassociated with clinically detected complications. Further studies are needed in diabetic patients with impaired gastric motor function.
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Affiliation(s)
- A Vella
- Enteric Neuroscience Program, Gastroenterology Research Unit, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Viramontes BE, Malcolm A, Camilleri M, Szarka LA, McKinzie S, Burton DD, Zinsmeister AR. Effects of an alpha(2)-adrenergic agonist on gastrointestinal transit, colonic motility, and sensation in humans. Am J Physiol Gastrointest Liver Physiol 2001; 281:G1468-76. [PMID: 11705752 DOI: 10.1152/ajpgi.2001.281.6.g1468] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To characterize alpha(2)-adrenergic control of motor and sensory functions of gastrointestinal tract and colon, we studied dose-related effects of clonidine (placebo or up to 0.3 mg po) by random assignment in 55 healthy humans. Gastrointestinal transit was measured in all subjects; in 35, we assessed colonic compliance, tone, and sensations of gas and pain during phasic distensions. Clonidine did not significantly alter gastrointestinal or colonic transit, but it increased colonic compliance and reduced fasting tone without altering colonic response to a meal. Clonidine significantly reduced aggregate sensation to distensions overall and had significant linear dose-related sensory effects at 8- and 24-mmHg distensions. Effect on pain (including dose-response relationship) was due to 0.3-mg dose for distensions at 24 mmHg. We confirmed that clonidine relaxes fasting colonic tone and reduces sensation of pain. In this study, gut transit was not altered by clonidine, and novel dose-response characteristics and clonidine's effect on gas sensation are provided. Doses as low as 0.05 mg may be effective and potentially useful in reducing colonic tone and gas sensation.
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Affiliation(s)
- B E Viramontes
- Enteric Neuroscience Program, Gastroenterology Research Unit, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Abstract
Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.
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Affiliation(s)
- L A Szarka
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic, Rochester, Minn. 55905, USA
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Coulie B, Szarka LA, Camilleri M, Burton DD, McKinzie S, Stambler N, Cedarbaum JM. Recombinant human neurotrophic factors accelerate colonic transit and relieve constipation in humans. Gastroenterology 2000; 119:41-50. [PMID: 10889153 DOI: 10.1053/gast.2000.8553] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to assess the effects of recombinant human brain-derived neurotrophic factor (r-metHuBDNF) and recombinant human neurotrophic factor 3 (r-metHuNT-3) on gastrointestinal motor functions in healthy people and in patients with constipation. METHODS Gastrointestinal and colonic transit was measured by scintigraphy before and after 2 weeks of treatment. Daily diaries documented symptoms over 6 weeks before, during, and after treatment. In a randomized study of healthy subjects, 40 received 100 microg/kg r-metHuBDNF or placebo subcutaneously (SC) daily. In a separate study, 8 healthy subjects and 8 patients with constipation received 300 microg/kg r-metHuNT-3 SC thrice weekly. RESULTS r-met-HuBDNF accelerated overall and proximal colonic emptying (P<0.05) in health. r-metHuNT-3 accelerated overall colonic transit in health and constipation (all P<0.05) and gastric and small bowel transit (both P<0.05) in health. r-metHuBDNF tended to increase stool frequency compared with placebo in health (P = 0.09). r-metHuNT-3 increased stool frequency (P = 0.05) and facilitated passage of stool (P < 0.01) in constipated patients. The effects on stool frequency started within 3 days of the beginning of neurotrophin administrations and lasted up to 5 days after treatment ended. r-metHu neurotrophic factors were well tolerated, although half of the participants in the 2 studies developed injection site reactions or paresthesiae. CONCLUSIONS Exogenous neurotrophic factors stimulate human gut motility in health and constipation.
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Affiliation(s)
- B Coulie
- Gastroenterology Research Unit, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Samsom M, Szarka LA, Camilleri M, Vella A, Zinsmeister AR, Rizza RA. Pramlintide, an amylin analog, selectively delays gastric emptying: potential role of vagal inhibition. Am J Physiol Gastrointest Liver Physiol 2000; 278:G946-51. [PMID: 10859225 DOI: 10.1152/ajpgi.2000.278.6.g946] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The amylin analog pramlintide delays gastric emptying in type I diabetics. The effects of multiple doses of pramlintide and the mechanism of action in non-amylin-deficient humans are unknown. We investigated the effects of pramlintide on gastrointestinal and colonic transit and on the plasma pancreatic polypeptide response to the meal in a parallel-group dose-response study with subjects randomized to placebo, or 30 or 60 microg (tid, sc) of pramlintide. Pramlintide delayed gastric emptying [half-time (t(1/2)): 112 min (SE 8.7 min), 169 min (SE 12 min), or 177 min (SE 25 min) after placebo or 30- or 60-microg pramlintide treatment, respectively; P = 0.033]. Pramlintide did not significantly affect small bowel or colonic transit. Pancreatic polypeptide concentrations in the first postprandial hour were lower with pramlintide than with placebo (P<0.01 for drug effect). An inverse correlation was observed between mean pancreatic polypeptide concentrations in the first postprandial hour and gastric emptying t(1/2) [Spearman correlation coefficient (R(s)) = 0.48; P = 0.044]. Pramlintide at 30 and 60 microg delays gastric emptying in healthy humans without affecting small bowel or colonic transit. Vagal inhibition is a potential mechanism of the effects of pramlintide on gastric emptying.
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Affiliation(s)
- M Samsom
- Gastroenterology Research Unit, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Abstract
GERD is a common condition, generally caused by transient LES relaxations. The spectrum of disease due to GERD is wide, ranging from symptoms alone to esophagitis, Barrett's esophagus, and respiratory tract complications. Excellent diagnostic test are available to confirm the diagnosis and stage the disease, and medications can predictably relieve symptoms and heal even the most severe forms of esophagitis. Finally, surgical therapy is an effective option for patients with truly refractory disease or for those patients with significant disease who prefer not to use drug treatment.
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Affiliation(s)
- L A Szarka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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