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Jansson-Knodell CL, Krajicek EJ, Ramakrishnan M, Rogers NA, Siwiec R, Bohm M, Nowak T, Wo J, Lockett C, Xu H, Savaiano DA, Shin A. Relationships of Intestinal Lactase and the Small Intestinal Microbiome with Symptoms of Lactose Intolerance and Intake in Adults. Dig Dis Sci 2022; 67:5617-5627. [PMID: 35322314 PMCID: PMC11075758 DOI: 10.1007/s10620-022-07469-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 09/07/2021] [Accepted: 03/01/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Approximately two-thirds of adults are genetically predisposed to decreased lactase activity after weaning, putting them at risk of lactose intolerance. However, symptoms are a poor marker of lactose maldigestion. AIMS We assessed association between self-reported lactose intolerance and intestinal lactase, lactose intake, and the small intestinal microbiome. METHODS Patients 18-75 years presenting for upper endoscopy were recruited prospectively. Observational study participants completed a lactose intolerance symptom questionnaire and reported lactose intake. Post-bulbar biopsies were obtained to measure lactase activity and assess the small intestinal mucosal microbiome. We compared intestinal lactase between patients with and without lactose intolerance. We assessed associations between lactose intolerance symptoms and lactase and lactose intake. We examined associations of small bowel microbial composition with self-reported lactose intolerance and symptoms. RESULTS Among 34 patients, 23 (68%) reported lactose intolerance. Those with lactose intolerance had higher total symptom scores, more frequent bowel urgency, and more bowel movements after consuming dairy. The proportion of individuals with abnormal lactase activity did not differ by lactose intolerance status. Median lactase levels were correlated with total lactose intolerance symptom scores (p = 0.038) and frequency of bowel urgency (p = 0.012). Daily lactose intake did not differ between groups. In 19 patients, we observed significant associations of small intestinal microbiome beta diversity with stool consistency after consuming dairy (p = 0.03). CONCLUSIONS Intestinal lactase is associated with lactose intolerance symptoms and bowel urgency in adults but does not distinguish the clinical phenotype entirely. Studying other contributing factors (microbiota, diet) may further clarify the pathophysiology of lactose intolerance.
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Affiliation(s)
- Claire L Jansson-Knodell
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Edward J Krajicek
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Monica Ramakrishnan
- Department of Nutrition Science, Purdue University, 700 W State St, West Lafayette, IN, 47907, USA
| | - Nicholas A Rogers
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Robert Siwiec
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Matt Bohm
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Thomas Nowak
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - John Wo
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Carolyn Lockett
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Huiping Xu
- Department of Biostatistics and Health Sciences Data, Indiana University School of Medicine, 410 W 10th St, Indianapolis, IN, 46202, USA
| | - Dennis A Savaiano
- Department of Nutrition Science, Purdue University, 700 W State St, West Lafayette, IN, 47907, USA
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA.
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Bushyhead D, Quigley EMM. Small Intestinal Bacterial Overgrowth-Pathophysiology and Its Implications for Definition and Management. Gastroenterology 2022; 163:593-607. [PMID: 35398346 DOI: 10.1053/j.gastro.2022.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [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: 09/24/2021] [Revised: 03/28/2022] [Accepted: 04/03/2022] [Indexed: 12/19/2022]
Abstract
The concept of small intestinal bacterial overgrowth (SIBO) arose in the context of maldigestion and malabsorption among patients with obvious risk factors that permitted the small bowel to be colonized by potentially injurious colonic microbiota. Such colonization resulted in clinical signs, symptoms, and laboratory abnormalities that were explicable within a coherent pathophysiological framework. Coincident with advances in medical science, diagnostic testing evolved from small bowel culture to breath tests and on to next-generation, culture-independent microbial analytics. The advent and ready availability of breath tests generated a dramatic expansion in both the rate of diagnosis of SIBO and the range of associated gastrointestinal and nongastrointestinal clinical scenarios. However, issues with the specificity of these same breath tests have clouded their interpretation and aroused some skepticism regarding the role of SIBO in this expanded clinical repertoire. Furthermore, the pathophysiological plausibility that underpins SIBO as a cause of maldigestion/malabsorption is lacking in regard to its purported role in irritable bowel syndrome, for example. One hopes that the application of an ever-expanding armamentarium of modern molecular microbiology to the human small intestinal microbiome in both health and disease will ultimately resolve this impasse and provide an objective basis for the diagnosis of SIBO.
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Affiliation(s)
- Daniel Bushyhead
- Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas.
| | - Eamonn M M Quigley
- Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
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Abstract
PURPOSE OF REVIEW To evaluate recently published information about the frequency of maldigestion and malabsorption in older individuals, likely diagnoses causing these problems, and the diagnostic scheme when these diagnoses are being considered. RECENT FINDINGS Although the prevalence of malnourishment and frank malnutrition may be increasing among older adults admitted to the hospital, this appears to be due to reduced food intake rather than maldigestion or malabsorption. The mechanisms of food digestion and absorption seem to be resilient, even in old age, but concurrent illness may produce malabsorption in older individuals. Illnesses that may be more common among the elderly include small intestinal bacterial overgrowth, exocrine pancreatic insufficiency, enteropathies, vascular disease, diabetes, and certain infections, such as Whipple's disease. In addition, older adults may have had previous surgeries or exposure to medicines which may induce malabsorption. The presentation of maldigestion and malabsorption in the elderly may be different than in younger individuals, and this may contribute to delayed recognition, diagnosis, and treatment. Diagnostic testing for maldigestion and malabsorption generally is similar to that used in younger patients. Maldigestion and malabsorption occur in older individuals and require a high level of suspicion, especially when weight loss, sarcopenia, or nutrient deficiencies are present.
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Affiliation(s)
- Lawrence R Schiller
- Baylor University Medical Center, 260 Wadley Tower, 3500 Gaston Avenue, Dallas, TX, 75246, USA.
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Chaudhary A, Domínguez-ñoz JE, Layer P, Lerch MM. Pancreatic Exocrine Insufficiency as a Complication of Gastrointestinal Surgery and the Impact of Pancreatic Enzyme Replacement Therapy. Dig Dis 2020; 38:53-68. [PMID: 31422398 PMCID: PMC6979421 DOI: 10.1159/000501675] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [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: 11/19/2018] [Accepted: 06/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) is characterized by inadequate production, insufficient secretion, and/or inactivation of pancreatic enzymes, resulting in maldigestion. The aim of this review was to analyze the prevalence and pathophysiology of PEI resulting from gastrointestinal (GI) surgery and to examine the use of pancreatic enzyme replacement therapy (PERT) for effectively managing PEI. SUMMARY A targeted PubMed search was conducted for studies examining the prevalence and pathophysiology of PEI in patients following GI surgery and for studies assessing the effects of PERT in these patients. PEI is a common complication following GI surgery that can lead to nutritional deficiencies, which may contribute to morbidity and mortality in patients. Timely treatment of PEI with PERT can prevent malnutrition, increase quality of life, and possibly reduce the associated mortality. Treatment of PEI should aim not only to alleviate symptoms but also to achieve significant improvements in nutritional parameters. Dose optimization of PERT is required for effective management of PEI, in addition to regular assessment of nutritional status, appropriate patient education, and reassessment if symptoms return. Key Messages: Difficulties in detecting PEI following GI surgery can result in undiagnosed and untreated maldigestion, leading to metabolic complications and increased morbidity. Both are preventable by early administration and monitoring for optimal doses of PERT.
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Affiliation(s)
- Adarsh Chaudhary
- aDepartment of Gastrointestinal Surgery, Gastrointestinal Oncology and Bariatric Surgery, Medanta, The Medicity, Gurgaon, India,*Adarsh Chaudhary, Department of Gastrointestinal Surgery, Gastrointestinal Oncology and Bariatric Surgery, Medanta, The Medicity, Sector 38, Gurgaon 122018 (India), E-Mail
| | - J. Enrique Domínguez-ñoz
- bDepartment of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Peter Layer
- cDepartment of Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - Markus M. Lerch
- dDepartment of Medicine, University Medicine Greifswald, Greifswald, Germany
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Yerushalmy-Feler A, Soback H, Lubetzky R, Ben-Tov A, Dali-Levy M, Galai T, Cohen S. One-third of children with lactose intolerance managed to achieve a regular diet at the three-year follow-up point. Acta Paediatr 2018; 107:1389-1394. [PMID: 29505134 DOI: 10.1111/apa.14305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 08/21/2017] [Revised: 11/30/2017] [Accepted: 02/28/2018] [Indexed: 12/20/2022]
Abstract
AIM This study described outcomes following treatment for lactose intolerance, which is common in children. METHODS The medical records of children aged 6-18 years who underwent lactose hydrogen breath testing at Dana-Dwek Children's Hospital, Tel Aviv, Israel, from August 2012 to August 2014 were analysed. We compared 154 children with gastrointestinal symptoms and positive lactose hydrogen breath tests to 49 children with negative test results. RESULTS Of the 154 children in the study group, 89 (57.8%) were advised to follow a lactose-restricted diet, 32 (20.8%) were advised to avoid lactose completely, 18 (11.7%) were instructed to use substitute enzymes, and 15 (9.7%) did not receive specific recommendations. Only 11 patients (7.1%) received recommendations to add calcium-rich foods or calcium supplements to their diet. Lactose reintroduction was attempted in 119 of 154 patients (77.3%), and 65 of 154 (42.2%) experienced clinical relapses. At the final follow-up of 3.3 years, 62.3% of the study children were still observing a restricted diet. Older children and those who were symptomatic during lactose hydrogen breath testing were more likely to be on a prolonged restricted diet. CONCLUSION Our long-term follow-up of lactose-intolerant children showed that only a third were able to achieve a regular diet.
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Affiliation(s)
- Anat Yerushalmy-Feler
- The Pediatric Gastroenterology Unit; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Hagai Soback
- The Pediatrics Department; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Ronit Lubetzky
- The Pediatrics Department; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Amir Ben-Tov
- The Pediatric Gastroenterology Unit; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Margalit Dali-Levy
- The Pediatric Gastroenterology Unit; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Tut Galai
- The Pediatric Gastroenterology Unit; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shlomi Cohen
- The Pediatric Gastroenterology Unit; ‘Dana-Dwek’ Children's Hospital; Tel Aviv Sourasky Medical Center; affiliated to the Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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Abstract
Malabsorption syndrome refers to the small intestines' inability to absorb certain nutrients and fluids. There are several common associated disorders, which may present with subtle and/or overt symptoms. With subtle symptoms, it is difficult to determine the cause, making diagnosis difficult or even inaccurate. Malabsorption can originate from an immune response, an inflammatory process, or alternation of the small intestines by surgical methods. This article reviews common malabsorption disease processes of the small bowel and the resulting pathophysiology. Diagnostic studies, treatment, and prognosis of various conditions within the malabsorption disease state are discussed.
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Abstract
Physiological digestion and absorption of nutrients within the gastrointestinal tract requires a complex interaction between motor, secretory, digestive, and absorptive functions that is vulnerable to a multitude of potential disturbances which may lead to global or specific malabsorption syndromes. Potential pathomechanisms that are illustrated in this article include insufficient mechanical breakdown of harder food components due to chewing problems and/or decreased antral contractility, critical reduction of time for absorption in patients with markedly enhanced upper gastrointestinal transit (e.g. dumping syndrome), impaired digestion and absorption of nutrient components caused by reduced gastric acid secretion, pancreatic exocrine insufficiency or reduced biliary secretion, defects of the enteral mucosa with enzyme deficiencies (e.g. disaccharidases) or lack of specific carrier mechanisms (e.g. hexose or aminoacid transporters), and critical quantitative loss of intestinal mucosa in patients with short bowel syndrome.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Germany
| | - Peter Layer
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Germany
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Li L, Somerset S. Digestive system dysfunction in cystic fibrosis: challenges for nutrition therapy. Dig Liver Dis 2014; 46:865-74. [PMID: 25053610 DOI: 10.1016/j.dld.2014.06.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/10/2014] [Accepted: 06/28/2014] [Indexed: 02/08/2023]
Abstract
Cystic fibrosis can affect food digestion and nutrient absorption. The underlying mutation of the cystic fibrosis trans-membrane regulator gene depletes functional cystic fibrosis trans-membrane regulator on the surface of epithelial cells lining the digestive tract and associated organs, where Cl(-) secretion and subsequently secretion of water and other ions are impaired. This alters pH and dehydrates secretions that precipitate and obstruct the lumen, causing inflammation and the eventual degradation of the pancreas, liver, gallbladder and intestine. Associated conditions include exocrine pancreatic insufficiency, impaired bicarbonate and bile acid secretion and aberrant mucus formation, commonly leading to maldigestion and malabsorption, particularly of fat and fat-soluble vitamins. Pancreatic enzyme replacement therapy is used to address this insufficiency. The susceptibility of pancreatic lipase to acidic and enzymatic inactivation and decreased bile availability often impedes its efficacy. Brush border digestive enzyme activity and intestinal uptake of certain disaccharides and amino acids await clarification. Other complications that may contribute to maldigestion/malabsorption include small intestine bacterial overgrowth, enteric circular muscle dysfunction, abnormal intestinal mucus, and intestinal inflammation. However, there is some evidence that gastric digestive enzymes, colonic microflora, correction of fatty acid abnormalities using dietary n-3 polyunsaturated fatty acid supplementation and emerging intestinal biomarkers can complement nutrition management in cystic fibrosis.
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Nagai M, Sho M, Satoi S, Toyokawa H, Akahori T, Yanagimoto H, Yamamoto T, Hirooka S, Yamaki S, Kinoshita S, Nishiwada S, Ikeda N, Kwon AH, Nakajima Y. Effects of pancrelipase on nonalcoholic fatty liver disease after pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 2013; 21:186-92. [PMID: 23798362 DOI: 10.1002/jhbp.14] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Postoperative nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) has recently become recognized. However, the pathoetiology of postoperative NAFLD is largely unknown. Furthermore, the optimal treatment has not been established. The aim of this prospective study was to clarify whether pancrelipase, which contains digestive pancreatic enzymes, could reverse NAFLD. METHODS A collaborative clinical trial has been conducted (UMIN000006841). A total of 30 patients who developed NAFLD after PD were prospectively treated with pancrelipase. NAFLD was defined and evaluated by the liver-to-spleen attenuation ratio on computed tomography (CT). Clinical symptoms and laboratory findings were also assessed. RESULTS The mean liver-to-spleen CT ratio before surgery in 30 patients was 1.233. It declined to 0.453 at diagnosis of NAFLD. It was significantly improved by the treatment and the CT ratios at 1, 3 and 6 months after treatment were 0.762, 0.958 and 0.904, respectively (vs. pretreatment, P < 0.001). The mild liver dysfunction was also improved. Total protein, albumin and total cholesterol levels were significantly improved by the treatment. Importantly, relatively severe diarrhea seen in 11 patients was also ameliorated. CONCLUSIONS Pancrelipase has a significant beneficial impact on NAFLD after PD. Maldigestion after pancreatic surgery may be a main cause for the development of postoperative NAFLD.
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Affiliation(s)
- Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
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Adrych K, Smoczynski M, Stojek M, Sledzinski T, Slominska E, Goyke E, Smolenski RT, Swierczynski J. Decreased serum essential and aromatic amino acids in patients with chronic pancreatitis. World J Gastroenterol 2010; 16:4422-7. [PMID: 20845509 PMCID: PMC2941065 DOI: 10.3748/wjg.v16.i35.4422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To investigate the influence of chronic pancreatitis (CP) on serum concentrations of amino acids.
METHODS: Thirty-five male patients with alcoholic CP and 21 healthy male subjects were examined. Serum concentrations of amino acids were assayed by ion-pair high-performance liquid chromatography with mass detection.
RESULTS: Serum glutamate concentration was increased in CP patients as compared to controls. In contrast, serum concentrations of glutamine, histidine, tyrosine, proline, tryptophan and threonine were significantly decreased in CP patients. A trend towards decreasing concentrations of serum lysine, alanine, methionine and valine as well as for total serum amino acids was observed. The sum of aromatic and the sum of essential amino acid concentrations were significantly lower in CP patients than in controls.
CONCLUSION: CP leads to decreased serum concentrations of several amino acids, such as essential and aromatic serum amino acids, most likely due to decreased exocrine function.
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Abstract
AIM: To investigate whether gastric myoelectrical activity was impaired in patients with chronic pancreatitis (CP) and to explore the role of pancreatic enzyme in regulating gastric myoelectrical activity.
METHODS: Twenty CP patients and 20 controls participated in the study. Gastric myoelectrical activity was recorded by a homemade electrogastrography (EGG) device. Two experiments were carried out. In experiment one, EGG was recorded in both controls and CP patients. While in experiment two, either pancreatic enzymes or placebo was given together with test meals. Spectral analysis was used to generate various EGG parameters.
RESULTS: The control subjects, but not the CP patients, showed typically increased postprandial dominant frequency. The postprandial dominant power (DP) increment (2.24±1.13 vs 5.35±0.96 dB, P = 0.04) and the percentage of normal 2-4 cpm slow waves (63.0±3.8% vs 77.4 ±3.1%, P<0.05) were lower in CP patients when compared with the control. In the 20 CP patients, the DP increment (4.76±1.02 vs 2.53±1.20 dB, P<0.05) and the postprandial percentage of normal 2-4 cpm (74.4±2.8% vs 64.8 ±5.7%, P<0.05) were significantly higher with pancreatic enzyme replacement than the placebo.
CONCLUSION: CP patients have an abnormal postprandial stomach myoelectricity showing poor response in dominant frequency/power and regularity, whereas these abnormalities are corrected after pancreatic enzyme replacement. Maldigestion is likely to be the factor leading to abnormal postprandial gastric myoelectricity of CP patients.
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Affiliation(s)
- Ching-Liang Lu
- Division of Gastroenterology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan, China.
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