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Kulkarni S, Saha M, Slosberg J, Singh A, Nagaraj S, Becker L, Zhang C, Bukowski A, Wang Z, Liu G, Leser JM, Kumar M, Bakhshi S, Anderson MJ, Lewandoski M, Vincent E, Goff LA, Pasricha PJ. Age-associated changes in lineage composition of the enteric nervous system regulate gut health and disease. eLife 2023; 12:RP88051. [PMID: 38108810 PMCID: PMC10727506 DOI: 10.7554/elife.88051] [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] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
The enteric nervous system (ENS), a collection of neural cells contained in the wall of the gut, is of fundamental importance to gastrointestinal and systemic health. According to the prevailing paradigm, the ENS arises from progenitor cells migrating from the neural crest and remains largely unchanged thereafter. Here, we show that the lineage composition of maturing ENS changes with time, with a decline in the canonical lineage of neural-crest derived neurons and their replacement by a newly identified lineage of mesoderm-derived neurons. Single cell transcriptomics and immunochemical approaches establish a distinct expression profile of mesoderm-derived neurons. The dynamic balance between the proportions of neurons from these two different lineages in the post-natal gut is dependent on the availability of their respective trophic signals, GDNF-RET and HGF-MET. With increasing age, the mesoderm-derived neurons become the dominant form of neurons in the ENS, a change associated with significant functional effects on intestinal motility which can be reversed by GDNF supplementation. Transcriptomic analyses of human gut tissues show reduced GDNF-RET signaling in patients with intestinal dysmotility which is associated with reduction in neural crest-derived neuronal markers and concomitant increase in transcriptional patterns specific to mesoderm-derived neurons. Normal intestinal function in the adult gastrointestinal tract therefore appears to require an optimal balance between these two distinct lineages within the ENS.
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Affiliation(s)
- Subhash Kulkarni
- Division of Gastroenterology, Dept of Medicine, Beth Israel Deaconess Medical CenterBostonUnited States
- Division of Medical Sciences, Harvard Medical SchoolBostonUnited States
| | - Monalee Saha
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Jared Slosberg
- Department of Genetic Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Alpana Singh
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Sushma Nagaraj
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Laren Becker
- Division of Gastroenterology, Stanford University – School of MedicineStanfordUnited States
| | - Chengxiu Zhang
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Alicia Bukowski
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Zhuolun Wang
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Guosheng Liu
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Jenna M Leser
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Mithra Kumar
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Shriya Bakhshi
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Matthew J Anderson
- Center for Cancer Research, National Cancer InstituteFrederickUnited States
| | - Mark Lewandoski
- Center for Cancer Research, National Cancer InstituteFrederickUnited States
| | - Elizabeth Vincent
- Department of Genetic Medicine, Johns Hopkins University – School of MedicineBaltimoreUnited States
| | - Loyal A Goff
- Department of Neuroscience, Johns Hopkins University – School of MedicineBaltimoreUnited States
- Kavli Neurodiscovery Institute, Johns Hopkins University – School of MedicineBaltimoreUnited States
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Konings B, Villatoro L, Van den Eynde J, Barahona G, Burns R, McKnight M, Hui K, Yenokyan G, Tack J, Pasricha PJ. Gastrointestinal syndromes preceding a diagnosis of Parkinson's disease: testing Braak's hypothesis using a nationwide database for comparison with Alzheimer's disease and cerebrovascular diseases. Gut 2023; 72:2103-2111. [PMID: 37620120 DOI: 10.1136/gutjnl-2023-329685] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/10/2023] [Accepted: 07/02/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Braak's hypothesis states that Parkinson's disease (PD) originates in the gastrointestinal (GI) tract, and similar associations have been established for Alzheimer's disease (AD) and cerebrovascular diseases (CVD). We aimed to determine the incidence of GI syndromes and interventions preceding PD compared with negative controls (NCs), AD and CVD. DESIGN We performed a combined case-control and cohort study using TriNetX, a US based nationwide medical record network. Firstly, we compared subjects with new onset idiopathic PD with matched NCs and patients with contemporary diagnoses of AD and CVD, to investigate preceding GI syndromes, appendectomy and vagotomy. Secondly, we compared cohorts with these exposures to matched NCs for the development of PD, AD and CVD within 5 years. RESULTS We identified 24 624 PD patients in the case-control analysis and matched 18 cohorts with each exposure to their NCs. Gastroparesis, dysphagia, irritable bowel syndrome (IBS) without diarrhoea and constipation showed specific associations with PD (vs NCs, AD and CVD) in both the case-control (odds ratios (ORs) vs NCs 4.64, 3.58, 3.53 and 3.32, respectively, all p<0.0001) and cohort analyses (relative risks (RRs) vs NCs 2.43, 2.27, 1.17 and 2.38, respectively, all p<0.05). While functional dyspepsia, IBS with diarrhoea, diarrhoea and faecal incontinence were not PD specific, IBS with constipation and intestinal pseudo-obstruction showed PD specificity in the case-control (OR 4.11) and cohort analysis (RR 1.84), respectively. Appendectomy decreased the risk of PD in the cohort analysis (RR 0.48). Neither inflammatory bowel disease nor vagotomy were associated with PD. CONCLUSION Dysphagia, gastroparesis, IBS without diarrhoea and constipation might specifically predict Parkinson's disease.
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Affiliation(s)
- Bo Konings
- Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven University Hospitals, Leuven, Belgium
| | - Luisa Villatoro
- Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Jef Van den Eynde
- Department of Cardiology, KU Leuven University Hospitals, Leuven, Belgium
| | | | - Robert Burns
- Department of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Megan McKnight
- Department of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Ken Hui
- Department of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jan Tack
- Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven University Hospitals, Leuven, Belgium
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Koshorek J, Wang Y, Maldonado DP, Reyes-Mantilla MI, Obando D, Balshi A, Comisac M, Pasricha PJ, Newsome SD. The many faces of gastrointestinal dysfunction in stiff person syndrome spectrum disorders. Front Neurol 2023; 14:1273256. [PMID: 37869142 PMCID: PMC10587580 DOI: 10.3389/fneur.2023.1273256] [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] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction The effect of stiff person syndrome spectrum disorders (SPSD) on the gastrointestinal tract (GIT) is unknown. This case series aims to characterize the prevalence and types of GI dysfunction in individuals with SPSD. Methods A retrospective chart review included individuals diagnosed with SPSD with descriptors of GI symptoms in their medical records. SPSD phenotypes, type of motility test performed, and dysmotility pattern (upper, lower, or diffuse) were assessed. Descriptive statistics and univariate chi-square analyses were utilized. Results Of 240 individuals with SPSD, 32% reported GI symptoms, most were female (83.1%), and white (74%), with a median age at time of GI symptom onset of 50 ± 13 years. Most common symptoms reported were dysphagia (45%), constipation (40%), and nausea/vomiting (23%). Most individuals had classic SPS (47%) followed by SPS-plus (29%) and 82.9% were positive for serum antiGAD65 antibodies. Of 36 patients that underwent at least one GI motility test, 26 had evidence of upper, lower, or diffuse GI dysmotility (44.4%, 17%, and 4%, respectively). The group who did not undergo testing had a higher proportion of patients with DM. Discussion There is a high prevalence of GI symptoms and transit abnormalities in patients with SPSD. Future prospective, longitudinal studies are warranted to further assess GI symptoms in the context of SPSD and to determine if individuals with GI symptoms differ in prognosis or treatment response from those without GI symptoms. In the meantime, there should be a low threshold for motility testing in patients with SPSD.
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Affiliation(s)
- Jacqueline Koshorek
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | | | - Maria I. Reyes-Mantilla
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Danielle Obando
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alexandra Balshi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael Comisac
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Pankaj Jay Pasricha
- Department of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Mayo Clinic in Arizona Department of Medicine, Scottsdale, AZ, United States
| | - Scott D. Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Pasricha PJ. New duodenoscope designs: not what we had hoped for. Gastrointest Endosc 2022; 96:567-568. [PMID: 35995465 DOI: 10.1016/j.gie.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/04/2022] [Indexed: 12/11/2022]
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Cordner ZA, Li Q, Liu L, Tamashiro KL, Bhargava A, Moran TH, Pasricha PJ. Vagal gut-brain signaling mediates amygdaloid plasticity, affect, and pain in a functional dyspepsia model. JCI Insight 2021; 6:144046. [PMID: 33591956 PMCID: PMC8026195 DOI: 10.1172/jci.insight.144046] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022] Open
Abstract
Functional dyspepsia (FD) is associated with chronic gastrointestinal distress and with anxiety and depression. Here, we hypothesized that aberrant gastric signals, transmitted by the vagus nerve, may alter key brain regions modulating affective and pain behavior. Using a previously validated rat model of FD characterized by gastric hypersensitivity, depression-like behavior, and anxiety-like behavior, we found that vagal activity - in response to gastric distention - was increased in FD rats. The FD phenotype was associated with gastric mast cell hyperplasia and increased expression of corticotrophin-releasing factor (Crh) and decreased brain-derived neurotrophic factor genes in the central amygdala. Subdiaphragmatic vagotomy reversed these changes and restored affective behavior to that of controls. Vagotomy partially attenuated pain responses to gastric distention, which may be mediated by central reflexes in the periaqueductal gray, as determined by local injection of lidocaine. Ketotifen, a mast cell stabilizer, reduced vagal hypersensitivity, normalized affective behavior, and attenuated gastric hyperalgesia. In conclusion, vagal activity, partially driven by gastric mast cells, induces long-lasting changes in Crh signaling in the amygdala that may be responsible for enhanced pain and enhanced anxiety- and depression-like behaviors. Together, these results support a "bottom-up" pathway involving the gut-brain axis in the pathogenesis of both gastric pain and psychiatric comorbidity in FD.
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Affiliation(s)
| | - Qian Li
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Liansheng Liu
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Aditi Bhargava
- Department of Obstetrics and Gynecology and The Center for Reproductive Sciences, UCSF, San Francisco, California, USA
| | | | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Affiliation(s)
- Subhash Kulkarni
- Center for Neurogastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland.
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7
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Beardslee LA, Banis GE, Chu S, Liu S, Chapin AA, Stine JM, Pasricha PJ, Ghodssi R. Ingestible Sensors and Sensing Systems for Minimally Invasive Diagnosis and Monitoring: The Next Frontier in Minimally Invasive Screening. ACS Sens 2020; 5:891-910. [PMID: 32157868 DOI: 10.1021/acssensors.9b02263] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ingestible electronic systems that are capable of embedded sensing, particularly within the gastrointestinal (GI) tract and its accessory organs, have the potential to screen for diseases that are difficult if not impossible to detect at an early stage using other means. Furthermore, these devices have the potential to (1) reduce labor and facility costs for a variety of procedures, (2) promote research for discovering new biomarker targets for associated pathologies, (3) promote the development of autonomous or semiautonomous diagnostic aids for consumers, and (4) provide a foundation for epithelially targeted therapeutic interventions. These technological advances have the potential to make disease surveillance and treatment far more effective for a variety of conditions, allowing patients to lead longer and more productive lives. This review will examine the conventional techniques, as well as ingestible sensors and sensing systems that are currently under development for use in disease screening and diagnosis for GI disorders. Design considerations, fabrication, and applications will be discussed.
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Affiliation(s)
- Luke A. Beardslee
- Institute for Systems Research, University of Maryland, College Park, Maryland 20742, United States
| | - George E. Banis
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland 20742, United States
| | - Sangwook Chu
- Institute for Systems Research, University of Maryland, College Park, Maryland 20742, United States
| | - Sanwei Liu
- Institute for Systems Research, University of Maryland, College Park, Maryland 20742, United States
| | - Ashley A. Chapin
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland 20742, United States
| | - Justin M. Stine
- Department of Electrical and Computer Engineering, University of Maryland, College Park, Maryland 20742, United States
| | - Pankaj Jay Pasricha
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland 21205, United States
| | - Reza Ghodssi
- Institute for Systems Research, University of Maryland, College Park, Maryland 20742, United States
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland 20742, United States
- Department of Electrical and Computer Engineering, University of Maryland, College Park, Maryland 20742, United States
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Joglekar P, Ding H, Canales-Herrerias P, Pasricha PJ, Sonnenburg JL, Peterson DA. Intestinal IgA Regulates Expression of a Fructan Polysaccharide Utilization Locus in Colonizing Gut Commensal Bacteroides thetaiotaomicron. mBio 2019; 10:e02324-19. [PMID: 31690674 PMCID: PMC6831775 DOI: 10.1128/mbio.02324-19] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/27/2019] [Indexed: 11/24/2022] Open
Abstract
Gut-derived immunoglobulin A (IgA) is the most abundant antibody secreted in the gut that shapes gut microbiota composition and functionality. However, most of the microbial antigens targeted by gut IgA remain unknown, and the functional effects of IgA targeting these antigens are currently understudied. This study provides a framework for identifying and characterizing gut microbiota antigens targeted by gut IgA. We developed a small intestinal ex vivo culture assay to harvest lamina propria IgA from gnotobiotic mice, with the aim of identifying antigenic targets in a model human gut commensal, Bacteroides thetaiotaomicron VPI-5482. Colonization by B. thetaiotaomicron induced a microbe-specific IgA response that was reactive against diverse antigens, including capsular polysaccharides, lipopolysaccharides, and proteins. IgA against microbial protein antigens targeted membrane and secreted proteins with diverse functionalities, including an IgA specific against proteins of the polysaccharide utilization locus (PUL) that are necessary for utilization of fructan, which is an important dietary polysaccharide. Further analyses demonstrated that the presence of dietary fructan increased the production of fructan PUL-specific IgA, which then downregulated the expression of fructan PUL in B. thetaiotaomicron, both in vivo and in vitro Since the expression of fructan PUL has been associated with the ability of B. thetaiotaomicron to colonize the gut in the presence of dietary fructans, our work suggests a novel role for gut IgA in regulating microbial colonization by modulating their metabolism.IMPORTANCE Given the significant impact that gut microbes have on our health, it is essential to identify key host and environmental factors that shape this diverse community. While many studies have highlighted the impact of diet on gut microbiota, little is known about how the host regulates this critical diet-microbiota interaction. In our present study, we discovered that gut IgA targeted a protein complex involved in the utilization of an important dietary polysaccharide: fructan. While the presence of dietary fructans was previously thought to allow unrestricted growth of fructan-utilizing bacteria, our work shows that gut IgA, by targeting proteins responsible for fructan utilization, provides the host with tools that can restrict the microbial utilization of such polysaccharides, thereby controlling their growth.
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Affiliation(s)
- Payal Joglekar
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, California, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hua Ding
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pablo Canales-Herrerias
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin L Sonnenburg
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel A Peterson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [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: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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10
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Liu L, Zhu Y, Noë M, Li Q, Pasricha PJ. Neuronal Transforming Growth Factor beta Signaling via SMAD3 Contributes to Pain in Animal Models of Chronic Pancreatitis. Gastroenterology 2018; 154:2252-2265.e2. [PMID: 29505748 PMCID: PMC5985212 DOI: 10.1053/j.gastro.2018.02.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 07/06/2017] [Revised: 02/15/2018] [Accepted: 02/26/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND & AIMS Chronic pancreatitis (CP) is characterized by pancreatic inflammation and fibrosis, associated with increased pancreatic expression of transforming growth factor beta (TGFB). It is not clear how these might contribute to pain. We investigated whether TGFB signaling via SMAD induces sensitization of pancreatic sensory neurons to increase nociception. METHODS CP was induced in Sprague-Dawley rats by infusion of trinitrobenzene sulfonic acid; some rats were given intrathecal infusions of TGFB1. CP was induced in control mice by administration of cerulein; we also studied β1glo/Ptf1acre-ER mice, which on induction overexpress TGFB1 in pancreatic acinar cells, and TGFBr1f/f-CGRPcreER mice, which have inducible disruption of TGFBr1 in calcitonin gene-related peptide-positive neurons. Dominant negative forms of human TGFBR2 and SMAD3 were overexpressed from viral vectors in rat pancreas. Some rats were given the SMAD3 inhibitors SIS3 or halofuginone. After induction of CP, mice were analyzed for pain in behavior tests or electrophysiologic studies of sensory neurons. Pancreatic nociceptor excitability was examined by patch-clamp techniques and nociception was measured by Von Frey Filament tests for referred somatic hyperalgesia and behavioral responses to pancreatic electrical stimulation. Pancreata were collected from mice and rats and analyzed histologically and by enzyme-linked immunosorbent assay and immunohistochemistry. RESULTS Overexpression of TGFB in pancreatic acinar cells of mice and infusion of TGFB1 into rats resulted in sensory neuron hyperexcitability, SMAD3 activation, and increased nociception. This was accompanied by a reduction in the transient A-type current in pancreas-specific sensory neurons in rats, a characteristic of nociceptive sensitization in animal models of CP. Conversely, pancreata from TGFBr1f/f-CGRPcreER mice, rats with pancreatic expression of dominant negative forms of human TGFBR2 or SMAD3, and rats given small molecule inhibitors of SMAD3 had attenuated neuronal sensitization and pain behavior following induction of CP. In contrast to findings from peripheral administration of TGFB1, intrathecal infusion of TGFB1 reduced hyperalgesia in rats with CP. CONCLUSIONS In pancreata of mice and rats, TGFB promotes peripheral nociceptive sensitization via a direct effect on primary sensory neurons mediated by intra-neuronal SMAD3. This is distinct from the central nervous system, where TGFB reduces nociception. These results provide an explanation for the link between fibrosis and pain in patients with CP. This signaling pathway might be targeted therapeutically to reduce pain in patients with CP.
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Affiliation(s)
- Liansheng Liu
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yaohui Zhu
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michaël Noë
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Qian Li
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pankaj Jay Pasricha
- Johns Hopkins Center for Neurogastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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11
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Becker L, Nguyen L, Gill J, Kulkarni S, Pasricha PJ, Habtezion A. Age-dependent shift in macrophage polarisation causes inflammation-mediated degeneration of enteric nervous system. Gut 2018; 67:827-836. [PMID: 28228489 PMCID: PMC5565713 DOI: 10.1136/gutjnl-2016-312940] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [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: 08/25/2016] [Revised: 12/21/2016] [Accepted: 01/27/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The enteric nervous system (ENS) undergoes neuronal loss and degenerative changes with age. The cause of this neurodegeneration is poorly understood. Muscularis macrophages residing in close proximity to enteric ganglia maintain neuromuscular function via direct crosstalk with enteric neurons and have been implicated in the pathogenesis of GI motility disorders like gastroparesis and postoperative ileus. The aim of this study was to assess whether ageing causes alterations in macrophage phenotype that contributes to age-related degeneration of the ENS. DESIGN Longitudinal muscle and myenteric plexus from small intestine of young, mid-aged and old mice were dissected and prepared for whole mount immunostaining, flow cytometry, Luminex immunoassays, western blot analysis, enteric neural stem cell (ENSC) isolation or conditioned media. Bone marrow derived macrophages were prepared and polarised to classic (M1) or alternative (M2) activation states. Markers for macrophage phenotype were measured using quantitative RT-PCR. RESULTS Ageing causes a shift in macrophage polarisation from anti-inflammatory 'M2' to proinflammatory 'M1' that is associated with a rise in cytokines and immune cells in the ENS. This phenotypic shift is associated with a neural response to inflammatory signals, increase in apoptosis and loss of enteric neurons and ENSCs, and delayed intestinal transit. An age-dependent decrease in expression of the transcription factor FoxO3, a known longevity gene, contributes to the loss of anti-inflammatory behaviour in macrophages of old mice, and FoxO3-deficient mice demonstrate signs of premature ageing of the ENS. CONCLUSIONS A shift by macrophages towards a proinflammatory phenotype with ageing causes inflammation-mediated degeneration of the ENS.
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Affiliation(s)
- Laren Becker
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California,Corresponding Authors Contact Information: Laren Becker, MD, PhD, Stanford University School of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, 300 Pasteur Drive, Stanford, CA 94305, Tel: 650 721 1264, Fax: 650 723 5488, . Aida Habtezion, MD MSc, Stanford University School of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, 300 Pasteur Drive, Stanford, CA 94305, Tel: 650 725 6511, Fax: 650 723 5488,
| | - Linh Nguyen
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - Jaspreet Gill
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - Subhash Kulkarni
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Pankaj Jay Pasricha
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland
| | - Aida Habtezion
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California,Corresponding Authors Contact Information: Laren Becker, MD, PhD, Stanford University School of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, 300 Pasteur Drive, Stanford, CA 94305, Tel: 650 721 1264, Fax: 650 723 5488, . Aida Habtezion, MD MSc, Stanford University School of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, 300 Pasteur Drive, Stanford, CA 94305, Tel: 650 725 6511, Fax: 650 723 5488,
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12
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Hasler WL, May KP, Wilson LA, Van Natta M, Parkman HP, Pasricha PJ, Koch KL, Abell TL, McCallum RW, Nguyen LA, Snape WJ, Sarosiek I, Clarke JO, Farrugia G, Calles-Escandon J, Grover M, Tonascia J, Lee LA, Miriel L, Hamilton FA. Relating gastric scintigraphy and symptoms to motility capsule transit and pressure findings in suspected gastroparesis. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13196. [PMID: 28872760 PMCID: PMC6004323 DOI: 10.1111/nmo.13196] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [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: 04/06/2017] [Accepted: 07/25/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Wireless motility capsule (WMC) findings are incompletely defined in suspected gastroparesis. We aimed to characterize regional WMC transit and contractility in relation to scintigraphy, etiology, and symptoms in patients undergoing gastric emptying testing. METHODS A total of 209 patients with gastroparesis symptoms at NIDDK Gastroparesis Consortium centers underwent gastric scintigraphy and WMCs on separate days to measure regional transit and contractility. Validated questionnaires quantified symptoms. KEY RESULTS Solid scintigraphy and liquid scintigraphy were delayed in 68.8% and 34.8% of patients; WMC gastric emptying times (GET) were delayed in 40.3% and showed 52.8% agreement with scintigraphy; 15.5% and 33.5% had delayed small bowel (SBTT) and colon transit (CTT) times. Transit was delayed in ≥2 regions in 23.3%. Rapid transit was rarely observed. Diabetics had slower GET but more rapid SBTT versus idiopathics (P ≤ .02). GET delays related to greater scintigraphic retention, slower SBTT, and fewer gastric contractions (P ≤ .04). Overall gastroparesis symptoms and nausea/vomiting, early satiety/fullness, bloating/distention, and upper abdominal pain subscores showed no relation to WMC transit. Upper and lower abdominal pain scores (P ≤ .03) were greater with increased colon contractions. Constipation correlated with slower CTT and higher colon contractions (P = .03). Diarrhea scores were higher with delayed SBTT and CTT (P ≤ .04). CONCLUSIONS & INFERENCES Wireless motility capsules define gastric emptying delays similar but not identical to scintigraphy that are more severe in diabetics and relate to reduced gastric contractility. Extragastric transit delays occur in >40% with suspected gastroparesis. Gastroparesis symptoms show little association with WMC profiles, although lower symptoms relate to small bowel or colon abnormalities.
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Affiliation(s)
- W L Hasler
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - K P May
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - L A Wilson
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - M Van Natta
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - H P Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA, USA
| | - P J Pasricha
- Section of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - K L Koch
- Section on Gastroenterology, Wake Forest University, Winston Salem, NC, USA
| | - T L Abell
- Division of Gastroenterology, University of Louisville, Louisville, KY, USA
| | - R W McCallum
- Section of Gastroenterology, Texas Tech University, El Paso, TX, USA
| | - L A Nguyen
- Division of Gastroenterology, Stanford University, Palo Alto, CA, USA
| | - W J Snape
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, CA, USA
| | - I Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, TX, USA
| | - J O Clarke
- Division of Gastroenterology, Stanford University, Palo Alto, CA, USA
| | - G Farrugia
- Section of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - J Calles-Escandon
- Endocrinology Section, MetroHealth Medical Center, Cleveland, OH, USA
| | - M Grover
- Section of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - J Tonascia
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - L A Lee
- Section of Gastroenterology, Johns Hopkins University Data Coordinating Center, Baltimore, MD, USA
| | - L Miriel
- Data Coordinating Center, Johns Hopkins University, Baltimore, MD, USA
| | - F A Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
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13
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Chander Roland B, Mullin GE, Passi M, Zheng X, Salem A, Yolken R, Pasricha PJ. A Prospective Evaluation of Ileocecal Valve Dysfunction and Intestinal Motility Derangements in Small Intestinal Bacterial Overgrowth. Dig Dis Sci 2017; 62:3525-3535. [PMID: 28871499 DOI: 10.1007/s10620-017-4726-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/16/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) is an increasingly recognized clinical syndrome; however, its etiophathogenesis is poorly understood. We hypothesized that loss of gastric acid, a delayed intestinal transit, and ileocecal valve dysfunction may contribute to the genesis of this syndrome. AIMS Our primary aim was to assess these parameters using wireless motility capsule (WMC) testing and to correlate them with the presence or absence of SIBO. METHODS We prospectively evaluated 30 consecutive patients at a tertiary care center with suspected SIBO, diagnosed by lactulose hydrogen breath testing (LBT), and small bowel aspirate microbiology. Patients underwent WMC testing to assess ileocecal junction pressure (ICJP), small bowel transit time (SBTT), and regional gastrointestinal pH. RESULTS Thirty patients completed testing; 15 had a positive LBT, and 11 had a positive aspirate culture. As compared with LBT-negative patients, ICJP was lower (27.8 vs. 72.7 mmHg, p = 0.027), SBTT was longer (10.0 vs. 1.1 h, p = 0.004), gastric pH was higher (3.63 vs. 2.42, p < 0.01), and small bowel pH was higher (6.96 vs. 6.61, p = 0.05). A hypotensive ICJP (<46.61 mmHg) was more prevalent in LBT-positive patients as compared with LBT-negative patients (73.3 vs. 14.29%, p = 0.003). Logistic regression models were used to assess the magnitude of each measured WMC parameter and the presence of SIBO. p values ≤0.05 were considered statistically significant. CONCLUSIONS Patients with SIBO have significantly lower ICJP, prolonged SBTT, and a higher gastrointestinal pH as compared to those without SIBO. These abnormalities may play different roles in the pathogenesis of SIBO, facilitating more targeted treatment to prevent recurrences of SIBO.
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Affiliation(s)
- Bani Chander Roland
- Division of Gastroenterology and Hepatology, Lenox Hill Hospital, Northwell Health System, New York, NY, USA.
| | - Gerard E Mullin
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Monica Passi
- Division of Gastroenterology, Northshore University Hospital, Northwell Health System, New York, NY, USA
| | - Xi Zheng
- Division of Gastroenterology, Nanjing, China
| | - Ahmed Salem
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Yolken
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pankaj Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Ahuja NK, Agnihotri A, Lynch KL, Hoo-Fatt D, Onyimba F, McKnight M, Okeke FC, Garcia P, Dhalla S, Stein E, Pasricha PJ, Clarke JO. Esophageal distensibility measurement: impact on clinical management and procedure length. Dis Esophagus 2017; 30:1-8. [PMID: 28575249 DOI: 10.1093/dote/dox038] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 08/29/2016] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
Abstract
Luminal distensibility measurement has demonstrated relevance to various disease processes, though its effects on clinical decision-making have been less well understood. This study aims to characterize the clinical impact of impedance planimetry measurement as well as the learning curve associated with its use in the esophagus. A single provider performed distensibility measurement in conjunction with upper endoscopy for a variety of clinical indications with the functional lumen imaging probe (FLIP) over a period of 21 months. Procedural data were prospectively collected and, along with medical records, retrospectively reviewed. Seventy-three procedures (70 patients) underwent esophageal distensibility measurement over the timeline of this study. The most common procedural indications were known or suspected achalasia (32.9%), dysphagia with connective tissue disease (13.7%), eosinophilic esophagitis (12.3%), and dysphagia with prior fundoplication (9.6%). FLIP results independently led to a change in management in 29 (39.7%) cases and supported a change in management in an additional 15 (20.5%) cases. The most common change in management was a new or amended therapeutic procedure (79.5%). Procedural time added by distensibility measurement was greater among earlier cases than among later cases. The median time added overall was 5 minutes and 46 seconds. Procedural time added varied significantly by procedural indication, but changes in management did not. Distensibility measurement added meaningful diagnostic information that impacted therapeutic decision-making in the majority of cases in which it was performed. Procedural time added by this modality is typically modest and decreases with experience.
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Affiliation(s)
- N K Ahuja
- Division of Gastroenterology and Hepatology
| | - A Agnihotri
- Department of Internal Medicine, Johns Hopkins Bayview Medical Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - K L Lynch
- Division of Gastroenterology and Hepatology
| | - D Hoo-Fatt
- Department of Internal Medicine, Johns Hopkins Bayview Medical Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - F Onyimba
- Division of Gastroenterology and Hepatology
| | - M McKnight
- Division of Gastroenterology and Hepatology
| | - F C Okeke
- Department of Internal Medicine, Johns Hopkins Bayview Medical Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Garcia
- Division of Gastroenterology and Hepatology
| | - S Dhalla
- Division of Gastroenterology and Hepatology
| | - E Stein
- Division of Gastroenterology and Hepatology
| | | | - J O Clarke
- Division of Gastroenterology and Hepatology
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15
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Drewes AM, Bouwense SAW, Campbell CM, Ceyhan GO, Delhaye M, Demir IE, Garg PK, van Goor H, Halloran C, Isaji S, Neoptolemos JP, Olesen SS, Palermo T, Pasricha PJ, Sheel A, Shimosegawa T, Szigethy E, Whitcomb DC, Yadav D. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 2017; 17:720-731. [PMID: 28734722 DOI: 10.1016/j.pan.2017.07.006] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [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: 03/23/2017] [Revised: 06/26/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.
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Affiliation(s)
- Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark.
| | - Stefan A W Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Myriam Delhaye
- Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Japan
| | - John P Neoptolemos
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
| | - Tonya Palermo
- Seattle Children's Hospital Research Institute, Washington School of Medicine, USA
| | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrea Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Tooru Shimosegawa
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Eva Szigethy
- Visceral Inflammation and Pain Center, Division of Gastroenterology, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
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16
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Grover M, Bernard CE, Pasricha PJ, Parkman HP, Gibbons SJ, Tonascia J, Koch KL, McCallum RW, Sarosiek I, Hasler WL, Nguyen LAB, Abell TL, Snape WJ, Kendrick ML, Kellogg TA, Hamilton FA, Farrugia G. Diabetic and idiopathic gastroparesis is associated with loss of CD206-positive macrophages in the gastric antrum. Neurogastroenterol Motil 2017; 29:10.1111/nmo.13018. [PMID: 28066953 PMCID: PMC5423829 DOI: 10.1111/nmo.13018] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [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: 09/07/2016] [Accepted: 11/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Animal studies have increasingly highlighted the role of macrophages in the development of delayed gastric emptying. However, their role in the pathophysiology of human gastroparesis is unclear. Our aim was to determine changes in macrophages and other cell types in the gastric antrum muscularis propria of patients with diabetic and idiopathic gastroparesis. METHODS Full thickness gastric antrum biopsies were obtained from patients enrolled in the Gastroparesis Clinical Research Consortium (11 diabetic, 6 idiopathic) and 5 controls. Immunolabeling and quantitative assessment was done for interstitial cells of Cajal (ICC) (Kit), enteric nerves protein gene product 9.5, neuronal nitric oxide synthase, vasoactive intestinal peptide, substance P, tyrosine hydroxylase), overall immune cells (CD45) and anti-inflammatory macrophages (CD206). Gastric emptying was assessed using nuclear medicine scintigraphy and symptom severity using the Gastroparesis Cardinal Symptom Index. RESULTS Both diabetic and idiopathic gastroparesis patients showed loss of ICC as compared to controls (Mean [standard error of mean]/hpf: diabetic, 2.28 [0.16]; idiopathic, 2.53 [0.47]; controls, 6.05 [0.62]; P=.004). Overall immune cell population (CD45) was unchanged but there was a loss of anti-inflammatory macrophages (CD206) in circular muscle (diabetic, 3.87 [0.32]; idiopathic, 4.16 [0.52]; controls, 6.59 [1.09]; P=.04) and myenteric plexus (diabetic, 3.83 [0.27]; idiopathic, 3.59 [0.68]; controls, 7.46 [0.51]; P=.004). There was correlation between the number of ICC and CD206-positive cells (r=.55, P=.008). Enteric nerves (PGP9.5) were unchanged: diabetic, 33.64 (3.45); idiopathic, 41.26 (6.40); controls, 46.80 (6.04). CONCLUSION Loss of antral CD206-positive anti-inflammatory macrophages is a key feature in human gastroparesis and it is associates with ICC loss.
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Affiliation(s)
- M Grover
- Mayo Clinic, Enteric NeuroScience Program, Rochester, MN, USA
| | - CE Bernard
- Mayo Clinic, Enteric NeuroScience Program, Rochester, MN, USA
| | - PJ Pasricha
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - HP Parkman
- Temple University, Philadelphia, PA, USA
| | - SJ Gibbons
- Mayo Clinic, Enteric NeuroScience Program, Rochester, MN, USA
| | - J Tonascia
- Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - KL Koch
- Wake Forest University, Winston-Salem, NC, USA
| | | | | | - WL Hasler
- University of Michigan, Ann Arbor, MI, USA
| | | | - TL Abell
- University of Louisville, Louisville, KY, USA
| | - WJ Snape
- California Pacific Medical Center, San Francisco, CA, USA
| | - ML Kendrick
- Mayo Clinic, Enteric NeuroScience Program, Rochester, MN, USA
| | - TA Kellogg
- Mayo Clinic, Enteric NeuroScience Program, Rochester, MN, USA
| | - FA Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - G Farrugia
- Mayo Clinic, Enteric NeuroScience Program, Rochester, MN, USA
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17
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Wu GJ, Xu F, Lin L, Pasricha PJ, Chen JDZ. Anorectal manometry: Should it be performed in a seated position? Neurogastroenterol Motil 2017; 29. [PMID: 27910245 DOI: 10.1111/nmo.12997] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 05/07/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anorectal manometry (ARM) is typically preformed in a lateral position. This non-physiological testing position has produced an unexpected negative rectoanal pressure gradient (RAPG, i.e. difference between rectal and anal pressure) with normal defecation. This study was designed (i) to study differences in ARM parameters between water-perfused and solid-state sensors and between lateral and seated positions and (ii) to investigate the roles of ARM parameters in predicting balloon expulsion. METHODS ARM was performed in 18 healthy volunteers (HV) and 60 patients with functional constipation (FC) under three randomized conditions: water-perfused in lateral position, solid-state in lateral position, and solid-state in seated position, followed by a balloon expulsion test in seated position. KEY RESULTS i) Under the same lateral position, solid-state sensors produced higher rectal resting pressure and RAPG than water-perfused sensors. ii) Using the solid-state sensors, ARM in the seated position revealed higher resting rectal pressure (34.9 vs 10.9 mmHg in HV, 30.9 vs 10.6 mmHg in FC, both P<.001) and higher RAPG (22.6 vs -6.2 mmHg in HV, 17.1 vs -8.1 mmHg in FC, both P<.001) than the lateral position. iii) When ARM was performed using solid-state sensors in seated position, RAPG was predictive of balloon expulsion; using 10 mmHg as a threshold, RAPG could predict balloon expulsion with specificity of 82% and sensitivity 77%. CONCLUSIONS AND INFERENCE ARM performed in a seated position using solid-state sensors seems more accurate in assessing rectal pressure, and the RAPG measured under these conditions is predictive of balloon expulsion in FC patients.
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Affiliation(s)
- G-J Wu
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Division of Gastroenterology, Wuxi No.2 Hospital affiliated to Nanjing Medical University, Wuxi, China.,Ningbo Pace Translational Medical Research Center, Ningbo, China
| | - F Xu
- Division of Gastroenterology, Ningbo Yinzhou People's Hospital, Ningbo, China
| | - L Lin
- Division of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - J D Z Chen
- Ningbo Pace Translational Medical Research Center, Ningbo, China.,Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD, USA
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Abstract
INTRODUCTION Gastroparesis is defined by nausea, vomiting, pain, early satiety and bloating, and characterized by delayed gastric emptying without obvious structural abnormalities. Metoclopramide is widely used, increasing gastric emptying and inhibiting nausea and vomiting. Other drugs are available in certain countries and some are used 'off-label' because they increase gastric emptying or inhibit emesis. However, correlation between gastroparesis symptoms and rates of gastric emptying is poor. For anti-emetic drugs, dose-ranging and Phase III trials in gastroparesis are lacking. Areas covered: Gastric motility may still be disordered, leading to nausea, even though gastric emptying is unchanged. One hypothesis is that interstitial cells of Cajal (ICC) are damaged by diabetes leading to gastric dysrhythmia and nausea. Novel approaches to treatment of nausea also include the use of ghrelin receptor agonists, highlighting a link between appetite and nausea. Expert opinion: There is an urgent need to diversify away from historical drug targets. In particular, there is a need to control nausea by regulating ICC functions and/or by facilitating appetite via ghrelin receptor agonists. It is also important to note that different upper gastrointestinal disorders (gastroparesis, chronic unexplained nausea and vomiting, functional dyspepsia) are difficult to distinguish apart, suggesting wider therapeutic opportunity.
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Affiliation(s)
- Gareth J Sanger
- a Professor of Neuropharmacology , Blizard Institute and the National Centre for Bowel Research, Barts The London School of Medicine and Dentistry, Queen Mary University of London , London , UK
| | - Pankaj Jay Pasricha
- b Vice Chair of Medicine for Innovation and Commercialization , Johns Hopkins University School of Medicine, Director, Johns Hopkins Center for Neurogastroenterology, Professor of Medicine and Neurosciences, Professor of Innovation Management, Johns Hopkins Carey School of Business , Baltimore , MD , USA
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19
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Affiliation(s)
| | - William Snape
- California Pacific Medical Center, San Francisco, California
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20
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Pasricha PJ. Gastric emptying and symptoms: functional dyspepsia versus gastroparesis. Neurogastroenterol Motil 2016; 28:779. [PMID: 27106678 DOI: 10.1111/nmo.12801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 02/08/2023]
Affiliation(s)
- P J Pasricha
- Johns Hopkins Center for Neurogastroenterology, Johns Hopkins School of Medicine, Stanford, MA, USA.
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21
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Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Rome IV. Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2016; 150:S0016-5085(16)00224-9. [PMID: 27144629 DOI: 10.1053/j.gastro.2016.02.033] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/19/2022]
Abstract
The concept that motor disorders of the gallbladder, cystic duct and sphincter of Oddi can cause painful syndromes is attractive and popular, at least in the USA. However, the results of commonly performed ablative treatments (cholecystectomy and sphincterotomy) are not uniformly good. The predictive value of tests that are often used to diagnose dysfunction (dynamic gallbladder scintigraphy and sphincter manometry) is controversial. Evaluation and management of these patients is made difficult by the fluctuating symptoms and the placebo effect of invasive interventions. A recent stringent study has shown that sphincterotomy is no better than sham treatment in patients with post-cholecystectomy pain and little or no objective abnormalities on investigation, so that the old concept of sphincter of Oddi dysfunction (SOD) type III is discarded. ERCP approaches are no longer appropriate in that context. There is a pressing need for similar prospective studies to provide better guidance for clinicians dealing with these patients. We need to clarify the indications for cholecystectomy in patients with Functional Gallbladder Disorder (FGBD) and the relevance of sphincter dysfunction in patients with some evidence for biliary obstruction (previously SOD type II, now called "Functional Biliary Sphincter Disorder - FBSD") and with idiopathic acute recurrent pancreatitis.
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Affiliation(s)
- P B Cotton
- Medical University of South Carolina, Charleston, SC, USA.
| | - G H Elta
- University of Michigan, Ann Arbor, MI, USA
| | | | - P J Pasricha
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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22
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Sawas T, Dhalla S, Sayyar M, Pasricha PJ, Hernaez R. Systematic review with meta-analysis: pharmacological interventions for eosinophilic oesophagitis. Aliment Pharmacol Ther 2015; 41:797-806. [PMID: 25728929 DOI: 10.1111/apt.13147] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [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: 12/21/2014] [Revised: 01/06/2015] [Accepted: 02/11/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is a growing cause of dysphagia. Current therapies include dietary manipulation, steroids and biological drugs. AIM To perform a systematic review and summarise the effect of different medical interventions on EoE. METHODS Two reviewers searched Pubmed and Embase for studies on treatment for EoE. We included randomised controlled trials (RCT) limited to pharmacological interventions. Two reviewers selected studies. Meta-analysis was done using random effects model to estimate odds ratio (OR). Heterogeneity was determined by Cochran's Q statistic and I(2) . RESULTS Seventeen references met our inclusion criteria. Eleven RCTs involving 455 participants were included in the meta-analysis. 325 participants were evaluated for symptomatic improvement and 330 were evaluated for histological remission. Symptomatic improvement with topical steroids (7 studies, 250 participants) compared to the control group (placebo or PPI) was noted (OR: 3.03, 95% confidence interval, CI: 1.57-5.87). Histological remission was also noted in nine studies involving 330 participants (OR: 13.66, 95% CI: 2.65-70.34) comparing topical steroids to a control (placebo or PPI). There was no difference between anti-IL-5 drugs and placebo in terms of symptomatic improvement (OR: 0.69, 95% CI: 0.34-1.42). CONCLUSIONS Topical steroids induce significant symptomatic and histological remission, and should be considered as a first line treatment. Anti-IL-5 therapy has a minor effect on eosinophilic oesophagitis. Future research in eosinophilic oesophagitis should standardise methodology according to published guidelines to improve quality and allow direct comparison between therapies.
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Affiliation(s)
- T Sawas
- Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
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23
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Affiliation(s)
- Henry P Parkman
- GI Section-Parkinson Pavilion 8th Floor, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - Pankaj Jay Pasricha
- Johns Hopkins Center for Neurogastroenterology, Johns Hopkins School of Medicine, Johns Hopkins Carey School of Business, 720 Rutland Street, Ross 958, Baltimore, MD 21205, USA.
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24
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Affiliation(s)
- Pankaj Jay Pasricha
- Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland; Food Body and Mind Center at Johns Hopkins, Baltimore, Maryland; Department of Medicine and Neurosciences, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Innovation Management, Johns Hopkins Carey School of Business, Baltimore, Maryland.
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25
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Abstract
Understanding of gastroparesis is evolving, in part because of systematic studies on the pathology, pathophysiology, and outcomes. It is clear that simply accelerating gastric emptying may not effectively control symptoms in this syndrome and more creative approaches are required that address aberrant sensation (vagal and spinal) as well as regional disturbances in motility. Further, with the growing recognition of a possible inflammatory basis, the prospects of disease modifying now seem realistic.
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Affiliation(s)
- Pankaj Jay Pasricha
- Department of Medicine, Johns Hopkins Center for Neurogastroenterology, Johns Hopkins School of Medicine, 720 Rutland Street, Ross 958, Baltimore, MD 21205, USA.
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26
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Pasricha PJ. Does the emptier have no clothes? Diabetes, gastric emptying, and the syndrome of gastroparesis. Clin Gastroenterol Hepatol 2015; 13:477-9. [PMID: 25451883 DOI: 10.1016/j.cgh.2014.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 10/29/2014] [Accepted: 10/29/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Pankaj Jay Pasricha
- Johns Hopkins Center for Neurogastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
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27
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Li C, Micci MA, Murthy KS, Pasricha PJ. Substance P is essential for maintaining gut muscle contractility: a novel role for coneurotransmission revealed by botulinum toxin. Am J Physiol Gastrointest Liver Physiol 2014; 306:G839-48. [PMID: 24699329 PMCID: PMC4347745 DOI: 10.1152/ajpgi.00436.2012] [Citation(s) in RCA: 12] [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] [Indexed: 01/31/2023]
Abstract
Substance P (SP) is commonly coexpressed with ACh in enteric motor neurons, and, according to the classical paradigm, both these neurotransmitters excite smooth muscle via parallel pathways. We hypothesized that, in addition, SP was responsible for maintaining the muscular responsiveness to ACh. We tested this hypothesis by using botulinum toxin (BoNT/A), a known blocker of vesicular release of neurotransmitters including ACh and neuropeptides. BoNT/A was injected into rat pyloric sphincter in different doses; as control we used boiled BoNT/A. At the desired time point, pylorus was dissected out and pyloric contractility was measured ex vivo in an organ bath and by measuring phosphorylation of myosin light chain 20 (MLC20). BoNT/A (10 IU) significantly reduced the response of pyloric muscle to exogenous ACh, an effect that was accompanied by reduced MLC20 phosphorylation in the muscle. Both effects were reversed by exogenous SP. CP-96345, a NK1 receptor antagonist, blocked the ability of exogenous SP to reverse the cholinergic hyporesponsiveness as well as the reduction in MLC20 phosphorylation induced by BoNT/A. In conclusion, we have identified a novel role for SP as a coneurotransmitter that appears to be important for the maintenance of muscular responsiveness to the principal excitatory neurotransmitter, ACh. These results also provide new insight into the effects of botulinum toxin on the enteric nervous system and gastrointestinal smooth muscle.
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Affiliation(s)
- Cuiping Li
- 1Johns Hopkins Center for Neurogastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
| | - Maria-Adelaide Micci
- 2Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas; and
| | - Karnam S. Murthy
- 3Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia
| | - Pankaj Jay Pasricha
- Johns Hopkins Center for Neurogastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland;
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28
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Park WG, Wu M, Bowen R, Zheng M, Fitch WL, Pai RK, Wodziak D, Visser BC, Poultsides GA, Norton JA, Banerjee S, Chen AM, Friedland S, Scott BA, Pasricha PJ, Lowe AW, Peltz G. Metabolomic-derived novel cyst fluid biomarkers for pancreatic cysts: glucose and kynurenine. Gastrointest Endosc 2013; 78:295-302.e2. [PMID: 23566642 PMCID: PMC3780566 DOI: 10.1016/j.gie.2013.02.037] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [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: 01/04/2013] [Accepted: 02/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Better pancreatic cyst fluid biomarkers are needed. OBJECTIVE To determine whether metabolomic profiling of pancreatic cyst fluid would yield clinically useful cyst fluid biomarkers. DESIGN Retrospective study. SETTING Tertiary-care referral center. PATIENTS Two independent cohorts of patients (n = 26 and n = 19) with histologically defined pancreatic cysts. INTERVENTION Exploratory analysis for differentially expressed metabolites between (1) nonmucinous and mucinous cysts and (2) malignant and premalignant cysts was performed in the first cohort. With the second cohort, a validation analysis of promising identified metabolites was performed. MAIN OUTCOME MEASUREMENTS Identification of differentially expressed metabolites between clinically relevant cyst categories and their diagnostic performance (receiver operating characteristic [ROC] curve). RESULTS Two metabolites had diagnostic significance-glucose and kynurenine. Metabolomic abundances for both were significantly lower in mucinous cysts compared with nonmucinous cysts in both cohorts (glucose first cohort P = .002, validation P = .006; and kynurenine first cohort P = .002, validation P = .002). The ROC curve for glucose was 0.92 (95% confidence interval [CI], 0.81-1.00) and 0.88 (95% CI, 0.72-1.00) in the first and validation cohorts, respectively. The ROC for kynurenine was 0.94 (95% CI, 0.81-1.00) and 0.92 (95% CI, 0.76-1.00) in the first and validation cohorts, respectively. Neither could differentiate premalignant from malignant cysts. Glucose and kynurenine levels were significantly elevated for serous cystadenomas in both cohorts. LIMITATIONS Small sample sizes. CONCLUSION Metabolomic profiling identified glucose and kynurenine to have potential clinical utility for differentiating mucinous from nonmucinous pancreatic cysts. These markers also may diagnose serous cystadenomas.
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Affiliation(s)
- Walter G. Park
- Department of Medicine, Stanford University, Stanford, California
| | - Manhong Wu
- Department of Anesthesiology, Stanford University, Stanford, California
| | - Raffick Bowen
- Department of Pathology, Stanford University, Stanford, California
| | - Ming Zheng
- Department of Anesthesiology, Stanford University, Stanford, California
| | - William L. Fitch
- Department of Anesthesiology, Stanford University, Stanford, California
| | - Reetesh K. Pai
- Department of Pathology, Stanford University, Stanford, California
| | - Dariusz Wodziak
- Department of Medicine, Stanford University, Stanford, California
| | - Brendan C. Visser
- Department of General Surgery, Stanford University, Stanford, California
| | | | - Jeff A. Norton
- Department of General Surgery, Stanford University, Stanford, California
| | - Subhas Banerjee
- Department of Medicine, Stanford University, Stanford, California
| | - Ann M. Chen
- Department of Medicine, Stanford University, Stanford, California
| | - Shai Friedland
- Department of Medicine, Stanford University, Stanford, California
| | - Brennan A. Scott
- Department of Gastroenterology, Palo Alto Medical Foundation, Palo Alto, California, USA
| | | | - Anson W. Lowe
- Department of Medicine, Stanford University, Stanford, California
| | - Gary Peltz
- Department of Anesthesiology, Stanford University, Stanford, California
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29
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Liu YA, Chung YC, Pan ST, Shen MY, Hou YC, Peng SJ, Pasricha PJ, Tang SC. 3-D imaging, illustration, and quantitation of enteric glial network in transparent human colon mucosa. Neurogastroenterol Motil 2013; 25:e324-38. [PMID: 23495930 DOI: 10.1111/nmo.12115] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [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: 10/09/2012] [Accepted: 02/15/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enteric glia form a network in the intestinal mucosa and have been suggested to engage in multidirectional interactions with the epithelium, blood vessels, nerves, and immune system. However, due to the dispersed nature of the glial network, standard histology cannot provide a global view of the network architecture. We prepared transparent human colon mucosa for three-dimensional (3-D) confocal microscopy with S100B immunostaining to reveal the location-dependent glial network for qualitative and quantitative analyses. METHODS Full-thickness human colons were acquired from colectomies performed for colorectal cancer. We targeted the mucosa away from the tumor site to characterize the glial network morphology. Optical clearing (use of immersion solution to reduce scattering) was applied to generate transparent specimens for deep-tissue microscopy. KEY RESULTS Two features of the glial network were seen: (i) A dense glial population resides at the crypt base/mucosal boundary in contact with the lymphatic vessels, and (ii) from the base, the glial network elongates along the crypt axis with peri-cryptic and peri-vascular connections toward the opening. We quantified the mucosal glia as the S100B-positive cells with at least two processes extending from the cell body. Examples of the global and in-depth imaging of adenoma were given to illustrate the morphological correlation between the loss of glial fibers and the aberrant crypts. CONCLUSIONS & INFERENCES We have established a useful approach for 3-D imaging, panoramic illustration, and quantitation of the enteric glia in the human colon mucosa to help characterize their roles with mucosal components in health and disease.
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Affiliation(s)
- Y A Liu
- Connectomics Research Center, National Tsing Hua University, Hsinchu, Taiwan
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30
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Becker L, Peterson J, Kulkarni S, Pasricha PJ. Ex vivo neurogenesis within enteric ganglia occurs in a PTEN dependent manner. PLoS One 2013; 8:e59452. [PMID: 23527198 PMCID: PMC3602370 DOI: 10.1371/journal.pone.0059452] [Citation(s) in RCA: 26] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 02/14/2013] [Indexed: 12/13/2022] Open
Abstract
A population of multipotent stem cells capable of differentiating into neurons and glia has been isolated from adult intestine in humans and rodents. While these cells may provide a pool of stem cells for neurogenesis in the enteric nervous system (ENS), such a function has been difficult to demonstrate in vivo. An extensive study by Joseph et al. involving 108 rats and 51 mice submitted to various insults demonstrated neuronal uptake of thymidine analog BrdU in only 1 rat. Here we introduce a novel approach to study neurogenesis in the ENS using an ex vivo organotypic tissue culturing system. Culturing longitudinal muscle and myenteric plexus tissue, we show that the enteric nervous system has tremendous replicative capacity with the majority of neural crest cells demonstrating EdU uptake by 48 hours. EdU+ cells express both neuronal and glial markers. Proliferation appears dependent on the PTEN/PI3K/Akt pathway with decreased PTEN mRNA expression and increased PTEN phosphorylation (inactivation) corresponding to increased Akt activity and proliferation. Inhibition of PTEN with bpV(phen) augments proliferation while LY294002, a PI3K inhibitor, blocks it. These data suggest that the ENS is capable of neurogenesis in a PTEN dependent manner.
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Affiliation(s)
- Laren Becker
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Johann Peterson
- Department of Pediatrics, University of California Davis, Sacramento, California, United States of America
| | - Subhash Kulkarni
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Pankaj Jay Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
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31
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Li C, Zhu Y, Shenoy M, Pai R, Liu L, Pasricha PJ. Anatomical and functional characterization of a duodeno-pancreatic neural reflex that can induce acute pancreatitis. Am J Physiol Gastrointest Liver Physiol 2013; 304:G490-500. [PMID: 23306082 PMCID: PMC3602681 DOI: 10.1152/ajpgi.00012.2012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [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
Neural cross talk between visceral organs may play a role in mediating inflammation and pain remote from the site of the insult. We hypothesized such a cross talk exists between the duodenum and pancreas, and further it induces pancreatitis in response to intraduodenal toxins. A dichotomous spinal innervation serving both the duodenum and pancreas was examined, and splanchnic nerve responses to mechanical stimulation of these organs were detected. This pathway was then excited on the duodenal side by exposure to ethanol followed by luminal mustard oil to activate transient receptor potential subfamily A, member 1 (TRPA1). Ninety minutes later, pancreatic inflammation was examined. Ablation of duodenal afferents by resiniferatoxin (RTX) or blocking TRPA1 by Chembridge (CHEM)-5861528 was used to further investigate the duodeno-pancreatic neural reflex via TRPA1. ~40% of dorsal root ganglia (DRG) from the spinal cord originated from both duodenum and pancreas via dichotomous peripheral branches; ~50% splanchnic nerve single units responded to mechanical stimulation of both organs. Ethanol sensitized TRPA1 currents in cultured DRG neurons. Pancreatic edema and myeloperoxidase activity significantly increased after intraduodenal ethanol followed by mustard oil (but not capsaicin) but significantly decreased after ablation of duodenal afferents by using RTX or blocking TRPA1 by CHEM-5861528. We found the existence of a neural cross talk between the duodenum and pancreas that can promote acute pancreatitis in response to intraduodenal chemicals. It also proves a previously unexamined mechanism by which alcohol can induce pancreatitis, which is novel both in terms of the site (duodenum), process (neurogenic), and receptor (TRPA1).
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Affiliation(s)
- Cuiping Li
- 1Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | - Yaohui Zhu
- 1Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | - Mohan Shenoy
- 1Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | - Reetesh Pai
- 2Department of Pathology, Stanford University, Stanford, California
| | - Liansheng Liu
- 1Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | - Pankaj Jay Pasricha
- 1Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
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32
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Affiliation(s)
- Ashish Nimgaonkar
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, California; Biodesign Program, Stanford University, Stanford, California.
| | - Paul G Yock
- Biodesign Program, Stanford University, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Todd J Brinton
- Biodesign Program, Stanford University, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Tom Krummel
- Biodesign Program, Stanford University, Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Pankaj Jay Pasricha
- Division of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland.
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Abstract
Gastrointestinal endoscopy has had a spectacular run in the last few decades with advances in technology that have redefined both gastroenterology and gastrointestinal surgery. Going forward, its contributions are likely to be even more meaningful as new procedures expand both the indications as well as the user base and contribute to bending the curve of healthcare costs. In this essay, I will describe some of what I believe to be the most important future developments with the greatest potential for impact across the spectrum of digestive disorders.
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Affiliation(s)
- Pankaj Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland 21224, USA.
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Chiu YC, Hua TE, Fu YY, Pasricha PJ, Tang SC. 3-D imaging and illustration of the perfusive mouse islet sympathetic innervation and its remodelling in injury. Diabetologia 2012; 55:3252-61. [PMID: 22930160 DOI: 10.1007/s00125-012-2699-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [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: 05/09/2012] [Accepted: 07/26/2012] [Indexed: 01/17/2023]
Abstract
AIMS/HYPOTHESIS Sympathetic nerves influence islet hormone levels in the circulation. Insights into islet sympathetic innervation and its remodelling in diabetes may impact future therapeutics. However, standard immunohistochemistry and microtome-based microscopy cannot provide an integral view of the islet neurovascular complex. We prepared transparent islet specimens to investigate the spatial relationship between sympathetic nerves, blood vessels and islet cells in normal, streptozotocin-injected and non-obese diabetic mouse models. METHODS Cardiac perfusion of fluorescent lectin was used to label pancreatic blood vessels. Tyrosine hydroxylase and nuclear staining were used to reveal islet sympathetic innervation and microstructure. Optical clearing (i.e. use of immersion solution to reduce scattering) was applied to enable 3-dimensional confocal microscopy of islets to visualise the sympathetic neurovascular complex in space. RESULTS Unlike previously reported morphology, we observed perfusive intra-islet, perivascular sympathetic innervation, in addition to peri-islet contacts of sympathetic nerves with alpha cells and sympathetic fibres encircling the adjacent arterioles. The intra-islet axons became markedly prominent in streptozotocin-injected mice (2 weeks after injection). In non-obese diabetic mice, lymphocytic infiltration remodelled the peri-islet sympathetic axons in early insulitis. CONCLUSIONS/INTERPRETATION We have established an imaging approach to reveal the spatial features of mouse islet sympathetic innervation. The neurovascular complex and sympathetic nerve-alpha cell contact suggest that sympathetic nerves modulate islet hormone secretion through blood vessels, in addition to acting directly on alpha cells. In islet injuries, sympathetic nerves undergo different remodelling in response to different pathophysiological cues.
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Affiliation(s)
- Y-C Chiu
- Connectomics Research Center, National Tsing Hua University, Hsinchu, Taiwan
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35
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Sasselli V, Micci MA, Kahrig KM, Pasricha PJ. Evaluation of ES-derived neural progenitors as a potential source for cell replacement therapy in the gut. BMC Gastroenterol 2012; 12:81. [PMID: 22735038 PMCID: PMC3412704 DOI: 10.1186/1471-230x-12-81] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 06/26/2012] [Indexed: 01/28/2023] Open
Abstract
Background Stem cell-based therapy has recently been explored for the treatment of disorders of the enteric nervous system (ENS). Pluripotent embryonic stem (ES) cells represent an attractive cell source; however, little or no information is currently available on how ES cells will respond to the gut environment. In this study, we investigated the ability of ES cells to respond to environmental cues derived from the ENS and related tissues, both in vitro and in vivo. Methods Neurospheres were generated from mouse ES cells (ES-NS) and co-cultured with organotypic preparations of gut tissue consisting of the longitudinal muscle layers with the adherent myenteric plexus (LM-MP). Results LM-MP co-culture led to a significant increase in the expression of pan-neuronal markers (βIII-tubulin, PGP 9.5) as well as more specialized markers (peripherin, nNOS) in ES-NS, both at the transcriptional and protein level. The increased expression was not associated with increased proliferation, thus confirming a true neurogenic effect. LM-MP preparations exerted also a myogenic effect on ES-NS, although to a lesser extent. After transplantation in vivo into the mouse pylorus, grafted ES-NS failed to acquire a distinct phenotype al least 1 week following transplantation. Conclusions This is the first study reporting that the gut explants can induce neuronal differentiation of ES cells in vitro and induce the expression of nNOS, a key molecule in gastrointestinal motility regulation. The inability of ES-NS to adopt a neuronal phenotype after transplantation in the gastrointestinal tract is suggestive of the presence of local inhibitory influences that prevent ES-NS differentiation in vivo.
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Affiliation(s)
- Valentina Sasselli
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
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Grover M, Bernard CE, Pasricha PJ, Lurken MS, Faussone-Pellegrini MS, Smyrk TC, Parkman HP, Abell TL, Snape WJ, Hasler WL, McCallum RW, Nguyen L, Koch KL, Calles J, Lee L, Tonascia J, Ünalp-Arida A, Hamilton FA, Farrugia G. Clinical-histological associations in gastroparesis: results from the Gastroparesis Clinical Research Consortium. Neurogastroenterol Motil 2012; 24:531-9, e249. [PMID: 22339929 PMCID: PMC3353102 DOI: 10.1111/j.1365-2982.2012.01894.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [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: 12/13/2022]
Abstract
BACKGROUND Cellular changes associated with diabetic (DG) and idiopathic gastroparesis (IG) have recently been described from patients enrolled in the Gastroparesis Clinical Research Consortium. The association of these cellular changes with gastroparesis symptoms and gastric emptying is unknown. The aim of this study was to relate cellular changes to symptoms and gastric emptying in patients with gastroparesis. METHODS Earlier, using full thickness gastric body biopsies from 20 DG, 20 IG, and 20 matched controls, we found decreased interstitial cells of Cajal (ICC) and enteric nerves and an increase in immune cells in both DG and IG. Here, demographic, symptoms [gastroparesis cardinal symptom index score (GCSI)], and gastric emptying were related to cellular alterations using Pearson's correlation coefficients. KEY RESULTS Interstitial cells of Cajal counts inversely correlated with 4 h gastric retention in DG but not in IG (r = -0.6, P = 0.008, DG, r = 0.2, P = 0.4, IG). There was also a significant correlation between loss of ICC and enteric nerves in DG but not in IG (r = 0.5, P = 0.03 for DG, r = 0.3, P = 0.16, IG). Idiopathic gastroparesis with a myenteric immune infiltrate scored higher on the average GCSI (3.6 ± 0.7 vs 2.7 ± 0.9, P = 0.05) and nausea score (3.8 ± 0.9 vs 2.6 ± 1.0, P = 0.02) as compared to those without an infiltrate. CONCLUSIONS & INFERENCES In DG, loss of ICC is associated with delayed gastric emptying. Interstitial cells of Cajal or enteric nerve loss did not correlate with symptom severity. Overall clinical severity and nausea in IG is associated with a myenteric immune infiltrate. Thus, full thickness gastric biopsies can help define specific cellular abnormalities in gastroparesis, some of which are associated with physiological and clinical characteristics of gastroparesis.
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Affiliation(s)
- M Grover
- Mayo Clinic, Rochester, MN 55905, USA
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Becker L, Kulkarni S, Tiwari G, Micci MA, Pasricha PJ. Divergent fate and origin of neurosphere-like bodies from different layers of the gut. Am J Physiol Gastrointest Liver Physiol 2012; 302:G958-65. [PMID: 22361728 PMCID: PMC3362075 DOI: 10.1152/ajpgi.00511.2011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [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] [Indexed: 01/31/2023]
Abstract
Enteric neural stem cells (ENSCs) are a population of neural crest-derived multipotent stem cells present in postnatal gut that may play an important role in regeneration of the enteric nervous system. In most studies, these cells have been isolated from the layer of the gut containing the myenteric plexus. However, a recent report demonstrated that neurosphere-like bodies (NLBs) containing ENSCs could be isolated from mucosal biopsy specimens from children, suggesting that ENSCs are present in multiple layers of the gut. The aim of our study was to assess whether NLBs isolated from layers of gut containing either myenteric or submucosal plexus are equivalent. We divided the mouse small intestine into two layers, one containing myenteric plexus and the other submucosal plexus, and assessed for NLB formation. Differences in NLB density, proliferation, apoptosis, neural crest origin, and phenotype were investigated. NLBs isolated from the myenteric plexus layer were present at a higher density and demonstrated greater proliferation, lower apoptosis, and higher expression of nestin, p75, Sox10, and Ret than those from submucosal plexus. Additionally, they contained a higher percentage of neural crest-derived cells (99.4 ± 1.5 vs. 0.7 ± 1.19% of Wnt1-cre:tdTomato cells; P < 0.0001) and produced more neurons and glial cells than those from submucosal plexus. NLBs from the submucosal plexus layer expressed higher CD34 and produced more smooth muscle-like cells. NLBs from the myenteric plexus layer contain more neural crest-derived ENSCs while those from submucosal plexus appear more heterogeneous, likely containing a population of mesenchymal stem cells.
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Affiliation(s)
- Laren Becker
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | - Subhash Kulkarni
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | - Gunjan Tiwari
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
| | | | - Pankaj Jay Pasricha
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, California; and
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Abstract
Current advances in our understanding of stem and precursor cell biology and in the protocols of stem cell isolation and transplantation have opened up the possibility of transplanting neural stem cells for the treatment of gastrointestinal motility disorders. This review summarises the current status of research in this field, identifies the major gaps in our knowledge and discusses the potential opportunities and hurdles for clinical application.
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Affiliation(s)
- Subhash Kulkarni
- Division of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, CA 94305, USA
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Dudley JT, Sirota M, Shenoy M, Pai RK, Roedder S, Chiang AP, Morgan AA, Sarwal MM, Pasricha PJ, Butte AJ. Computational repositioning of the anticonvulsant topiramate for inflammatory bowel disease. Sci Transl Med 2012; 3:96ra76. [PMID: 21849664 DOI: 10.1126/scitranslmed.3002648] [Citation(s) in RCA: 447] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract for which there are few safe and effective therapeutic options for long-term treatment and disease maintenance. Here, we applied a computational approach to discover new drug therapies for IBD in silico, using publicly available molecular data reporting gene expression in IBD samples and 164 small-molecule drug compounds. Among the top compounds predicted to be therapeutic for IBD by our approach were prednisolone, a corticosteroid used to treat IBD, and topiramate, an anticonvulsant drug not previously described to have efficacy for IBD or any related disorders of inflammation or the gastrointestinal tract. Using a trinitrobenzenesulfonic acid (TNBS)-induced rodent model of IBD, we experimentally validated our topiramate prediction in vivo. Oral administration of topiramate significantly reduced gross pathological signs and microscopic damage in primary affected colon tissue in the TNBS-induced rodent model of IBD. These findings suggest that topiramate might serve as a therapeutic option for IBD in humans and support the use of public molecular data and computational approaches to discover new therapeutic options for disease.
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Affiliation(s)
- Joel T Dudley
- Division of Systems Medicine, Department of Pediatrics, Stanford University School of Medicine, 251 Campus Drive, Stanford, CA 94305-5415, USA
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Abstract
Chronic pancreatitis is typically a painful condition and it can be associated with a severe burden of disease. The pathogenesis of pain in this disorder is poorly understood and its treatment has been largely empirical, often consisting of surgical or other invasive methods, with an outcome that is variable and frequently unsatisfactory. Human and experimental studies have indicated a critical role for neuronal mechanisms that result in peripheral and central sensitization. The pancreatic nociceptor seems to be significantly affected in this condition, with increased excitability associated with downregulation of potassium currents. Some of the specific molecules implicated in this process include the vanilloid receptor, TRPV1, nerve growth factor, the protease activated receptor 2 and a variety of others that are discussed in this Review. Studies have also indicated novel therapeutic targets for this condition.
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Affiliation(s)
- Pankaj Jay Pasricha
- Stanford University School of Medicine, 300 Pasteur Drive, M211 Alway Building, Stanford, CA 94305, USA.
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Zhu Y, Mehta K, Li C, Xu GY, Liu L, Colak T, Shenoy M, Pasricha PJ. Systemic administration of anti-NGF increases A-type potassium currents and decreases pancreatic nociceptor excitability in a rat model of chronic pancreatitis. Am J Physiol Gastrointest Liver Physiol 2012; 302:G176-81. [PMID: 22038828 PMCID: PMC3345962 DOI: 10.1152/ajpgi.00053.2011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [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
We have previously shown that pancreatic sensory neurons in rats with chronic pancreatitis (CP) display increased excitability associated with a decrease in transient inactivating potassium currents (I(A)), thus accounting in part for the hyperalgesia associated with this condition. Because of its well known role in somatic hyperalgesia, we hypothesized a role for the nerve growth factor (NGF) in driving these changes. CP was induced by intraductal injection of trinitrobenzene sulfonic acid (TNBS) in rats. After 3 wk, anti-NGF antibody or control serum was injected intra-peritoneally daily for 1 wk. This protocol was repeated in another set of experiments in control rats (receiving intraductal PBS instead of TNBS). Pancreatic nociceptors labeled with the dye Dil were identified, and patch-clamp recordings were made from acutely dissociated DRG neurons. Sensory neurons from anti-NGF-treated rats displayed a lower resting membrane potential, increased rheobase, decreased burst discharges in response to stimulatory current, and decreased input resistance compared with those treated with control serum. Under voltage-clamp condition, neuronal I(A) density was increased in anti-NGF-treated rats compared with rats treated with control serum. However, anti-NGF treatment had no effect on electrophysiological parameters in neurons from control rats. The expression of Kv-associated channel or ancillary genes Kv1.4, 4.1, 4.2, 4.3, and DPP6, DPP10, and KCHIPs 1-4 in pancreas-specific nociceptors was examined by laser-capture microdissection and real-time PCR quantification of mRNA levels. No significant differences were seen among those. These findings emphasize a key role for NGF in maintaining neuronal excitability in CP specifically via downregulation of I(A) by as yet unknown mechanisms.
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Affiliation(s)
- Yaohui Zhu
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Kshama Mehta
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Cuiping Li
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Guang-Yin Xu
- 2Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Liansheng Liu
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Tugba Colak
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Mohan Shenoy
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Pankaj Jay Pasricha
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
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Winawer SJ, Pasricha PJ, Schmiegel W, Sinicrope FA, Sung J, Seufferlein T, Kassem AM, Malekzadeh R, Kurtz RC, Classen M, Tytgat GN. The future role of the gastroenterologist in digestive oncology: an international perspective. Gastroenterology 2011; 141:e13-21. [PMID: 21871854 DOI: 10.1053/j.gastro.2011.08.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Sidney J Winawer
- Weill Medical College, Cornell University, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Liu YA, Chen Y, Chiang AS, Peng SJ, Pasricha PJ, Tang SC. Optical clearing improves the imaging depth and signal-to-noise ratio for digital analysis and three-dimensional projection of the human enteric nervous system. Neurogastroenterol Motil 2011; 23:e446-57. [PMID: 21895876 DOI: 10.1111/j.1365-2982.2011.01773.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [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: 02/08/2023]
Abstract
BACKGROUND Due to the dispersed nature of neurites and fibers, the microtome-based 2-dimensional histology provides only a limited perspective of the enteric nervous system. To visualize the enteric plexus, we applied optical clearing to avoid scattering in the human ileum to facilitate photon penetration for 3-dimensional (3-D) microscopy of the neural tissue. METHODS Human ileal specimens were derived by trimming the donor bowel due to its excess length during the clinical trial of small intestinal transplantation. The pan-neuronal marker PGP9.5 was used as the immunostaining target to reveal the enteric plexuses. The labeled tissues were immersed in the optical-clearing solution prior to deep-tissue confocal microscopy. The serial sections were digitally analyzed and processed by reconstruction algorithms for 3-D visualization. KEY RESULTS Optical clearing of the ileal specimen led to less fluorescence signal decay along the focal path in the tissue and a higher signal-to-noise ratio of the confocal micrographs in comparison with the untreated saline control. Taking advantage of the high signal-to-noise ratio images, we applied software-based signal analysis to identify the presence of the nerve fibers and quantify the signal peaks. The image stacks derived from the serial anatomic micrographs created panoramic views of the gut wall innervations with their associated microstructures. CONCLUSIONS & INFERENCES We provide an optical approach to improve the imaging depth in 3-D neurohistology of the human ileum. This methodology has significant promise in facilitating our understanding of the enteric nervous system in health and disease.
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Affiliation(s)
- Y-A Liu
- Department of Chemical Engineering, National Tsing Hua University, Hsinchu, Taiwan
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Kulkarni S, Zou B, Hanson J, Micci MA, Tiwari G, Becker L, Kaiser M, Xie X(S, Pasricha PJ. Gut-derived factors promote neurogenesis of CNS-neural stem cells and nudge their differentiation to an enteric-like neuronal phenotype. Am J Physiol Gastrointest Liver Physiol 2011; 301:G644-55. [PMID: 21817062 PMCID: PMC3191554 DOI: 10.1152/ajpgi.00123.2011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [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
Recent studies have explored the potential of central nervous system-derived neural stem cells (CNS-NSC) to repopulate the enteric nervous system. However, the exact phenotypic fate of gut-transplanted CNS-NSC has not been characterized. The aim of this study was to investigate the effect of the gut microenvironment on phenotypic fate of CNS-NSC in vitro. With the use of Transwell culture, differentiation of mouse embryonic CNS-NSC was studied when cocultured without direct contact with mouse intestinal longitudinal muscle-myenteric plexus preparations (LM-MP) compared with control noncocultured cells, in a differentiating medium. Differentiated cells were analyzed by immunocytochemistry and quantitative RT-PCR to assess the expression of specific markers and by whole cell patch-clamp studies for functional characterization of their phenotype. We found that LM-MP cocultured cells had a significant increase in the numbers of cells that were immune reactive against the panneuronal marker β-tubulin, neurotransmitters neuronal nitric oxide synthase (nNOS), choline acetyltransferase (ChAT), and neuropeptide vasoactive intestinal peptide (VIP) and showed an increase in expression of these genes, compared with control cells. Whole cell patch-clamp analysis showed that coculture with LM-MP decreases cell excitability and reduces voltage-gated Na(+) currents but significantly enhances A-current and late afterhyperpolarization (AHP) and increases the expression of the four AHP-generating Ca(2+)-dependent K(+) channel genes (KCNN), compared with control cells. In a separate experiment, differentiation of LM-MP cocultured CNS-NSC produced a significant increase in the numbers of cells that were immune reactive against the neurotransmitters nNOS, ChAT, and the neuropeptide VIP compared with CNS-NSC differentiated similarly in the presence of neonatal brain tissue. Our results show that the gut microenvironment induces CNS-NSC to produce neurons that share some of the characteristics of classical enteric neurons, further supporting the therapeutic use of these cells for gastrointestinal disorders.
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Affiliation(s)
- Subhash Kulkarni
- 1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California;
| | - Bende Zou
- 1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; ,2AfaSci Research Laboratory, Redwood City, California;
| | - Jesse Hanson
- 2AfaSci Research Laboratory, Redwood City, California; ,5Genentech, Inc., South San Francisco, California
| | - Maria-Adelaide Micci
- 3Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas;
| | - Gunjan Tiwari
- 1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California;
| | - Laren Becker
- 1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California;
| | - Martin Kaiser
- 4Department of Computer Science and Microsystems Technology, UAS, Kaiserlautern, Germany; and
| | - Xinmin (Simon) Xie
- 1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; ,2AfaSci Research Laboratory, Redwood City, California;
| | - Pankaj Jay Pasricha
- 1Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California;
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Liu L, Shenoy M, Pasricha PJ. Substance P and calcitonin gene related peptide mediate pain in chronic pancreatitis and their expression is driven by nerve growth factor. JOP 2011; 12:389-394. [PMID: 21737902 PMCID: PMC4090212] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CONTEXT Calcitonin gene-related peptide (CGRP), substance P and nerve growth factor play an important role in inflammatory pain in various somatic pain models but their role in chronic pancreatitis has not been well studied. OBJECTIVES The aim of this study was to investigate the effects of intrathecal administration of calcitonin gene-related peptide antagonist and substance P receptor antagonist on pain behavior in a rat model of chronic pancreatitis and to determine whether nerve growth factor drives the up-regulation of expression of these neuropeptides in sensory neurons. METHODS Pancreatitis was induced by retrograde infusion of trinitobenzene sulfonic acid into the pancreatic duct of adult rats. Three weeks post infusion continuous intrathecal infusion of the calcitonin gene-related peptide antagonist alpha CGRP8-37 or neurokinin-1 receptor antagonist CP-96345 or its inactive enantiomer CP-96344 was administered for seven days. The effects of treatment on pancreatic hyperalgesia were assessed by sensitivity of the abdominal wall to von Frey filament probing as well as by the nocifensive response to electrical stimulation of the pancreas. In a separate experiment chronic pancreatitis was induced and pancreas specific dorsal root ganglion neurons labeled with DiI were assessed for calcitonin gene-related peptide and substance P immunoreactivity. RESULTS Intrathecal infusion of calcitonin gene-related peptide and neurokinin-1 receptor antagonists significantly attenuated behavioral pain responses in rats with chronic pancreatitis. Further, treatment of chronic pancreatitis rats with nerve growth factor antibody significantly reduced pancreas specific neurons expressing calcitonin gene-related peptide and substance P in thoracic dorsal root ganglion. CONCLUSIONS Calcitonin gene-related peptide and substance P mediate pancreatic hyperalgesia in chronic pancreatitis and nerve growth factor in turn sustains the up-regulation of these neuropeptides in pancreatic sensory neurons.
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Affiliation(s)
- LianSheng Liu
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA, USA
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Abstract
BACKGROUND The amino acid γ-aminobutyric acid (GABA) is an important modulator of pain but its role in visceral pain syndromes is just beginning to be studied. Our aims were to investigate the effect and mechanism of action of the GABA(B) receptor agonist, baclofen, on gastric hypersensitivity in a validated rat model of functional dyspepsia (FD). METHODS 10-day-old male rats received 0.2 mL of 0.1% iodoacetamide in 2% sucrose daily by oral gavages for 6 days. Control group received 2% sucrose. At 8-10 weeks rats treated with baclofen (0.3, 1, and 3 mg kg(-1) bw) or saline were tested for behavioral and electromyographic (EMG) visceromotor responses; gastric spinal afferent nerve activity to graded gastric distention and Fos protein expression in dorsal horn of spinal cord segments T8-T10 to noxious gastric distention. KEY RESULTS Baclofen administration was associated with a significant attenuation of the behavioral and EMG responses (at 1 and 3 mg kg(-1)) and expression of Fos in T8 and T9 segments in neonatal iodoacetamide sensitized rats. However, baclofen administration did not significantly affect splanchnic nerve activity to gastric distention. Baclofen (3 mg kg(-1)) also significantly reduced the expression of spinal Fos in response to gastric distention in control rats to a lesser extent than sensitized rats. CONCLUSIONS & INFERENCES Baclofen is effective in attenuating pain associated responses in an experimental model of FD and appears to act by central mechanisms. These results provide a basis for clinical trials of this drug in FD patients.
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Affiliation(s)
- L S Liu
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA 94305-5187, USA
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Affiliation(s)
- Pankaj Jay Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Holmes S, Alekseyenko A, Timme A, Nelson T, Pasricha PJ, Spormann A. Visualization and statistical comparisons of microbial communities using R packages on Phylochip data. Pac Symp Biocomput 2011:142-53. [PMID: 21121042 PMCID: PMC3347925 DOI: 10.1142/9789814335058_0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This article explains the statistical and computational methodology used to analyze species abundances collected using the LNBL Phylochip in a study of Irritable Bowel Syndrome (IBS) in rats. Some tools already available for the analysis of ordinary microarray data are useful in this type of statistical analysis. For instance in correcting for multiple testing we use Family Wise Error rate control and step-down tests (available in the multtest package). Once the most significant species are chosen we use the hypergeometric tests familiar for testing GO categories to test specific phyla and families. We provide examples of normalization, multivariate projections, batch effect detection and integration of phylogenetic covariation, as well as tree equalization and robustification methods.
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Affiliation(s)
- Susan Holmes
- Statistics Department, Stanford University, Stanford, CA 94305, USA.
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Affiliation(s)
- Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305, USA.
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Abstract
BACKGROUND The aim of this study was to investigate the feasibility and mechanisms of controlling blood glucose using hepatic electrical stimulation (HES). METHODS The study was performed in regular Sprague-Dawley (SD) rats, streptozotocin-induced type 1 diabetic rats and Zucker diabetic fatty (ZDF) rats chronically implanted with one pair of stimulation electrodes on two lobes of the liver tissues. KEY RESULTS (i) Hepatic electrical stimulation was effective in reducing blood glucose by 27%-31% at time points 60, 75 and 90 min after oral glucose in normal rats; (ii) HES reduced blood glucose in both fasting and fed states in both type 1 and type 2 diabetic rats; (iii) Chronic HES decreased the blood glucose level, and, delayed gastric empty and increased plasma glucagon-like peptide-1 (GLP-1) level; and (iv) No adverse events were noted in any rats during HES. Histopathological analyses and liver function tests revealed no electrode dislodgement, tissue damages or liver enzyme changes with HES. CONCLUSIONS & INFERENCES Hepatic electrical stimulation is capable of reducing both fasting and fed blood glucose in normal, and type 1 and type 2 diabetic rats and the effect may be partially mediated via an increase in GLP-1 release.
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Affiliation(s)
- J Chen
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, TX 77555-0655, USA.
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