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Isaacson S, Phillips O, Jimenez-Shahed J. Hope vs. Hype III: Rescue/on-demand therapies are preferable to device-assisted therapies in Parkinson disease. Parkinsonism Relat Disord 2024:106079. [PMID: 38503575 DOI: 10.1016/j.parkreldis.2024.106079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Stuart Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, 951 NW 13th St, Bldg. 5-E, Boca Raton, FL, 33486, USA.
| | - Oliver Phillips
- Geisel School of Medicine at Dartmouth, Hanover, 18 Old Etna Road, Lebanon, NH, 03756, USA.
| | - Joohi Jimenez-Shahed
- Icahn School of Medicine at Mount Sinai, Mount Sinai West, 1000 10th Ave. Suite 10c, New York City, NY, 10019, USA.
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2
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Garcia A, Qureshi M, Dhawa I, Rafferty W, Budak-Alpdogan T, Giordano S. Isolated AL Amyloidosis of the Colon: A Rare Presentation. ACG Case Rep J 2024; 11:e01277. [PMID: 38328767 PMCID: PMC10849381 DOI: 10.14309/crj.0000000000001277] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
Amyloidosis is a group of rare deposition diseases marked by the accumulation of abnormal fibrillar proteins in the extracellular space of various tissues. In both AL and AA amyloidosis, the most common variants, isolated involvement to any one organ is uncommon and involvement to the colon alone is especially rare. We present the case of a patient who was initially found to have AL amyloidosis on prior screening colonoscopy that was reconfirmed several years with repeat evaluation for chronic constipation. This disease process is often insidious and can be overlooked by providers given the lack of overwhelming symptoms.
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Affiliation(s)
| | - Mahir Qureshi
- Department of Medicine, Cooper University Hospital, Camden, NJ
| | - Ishita Dhawa
- Department of Gastroenterology, Cooper University Hospital, Camden, NJ
| | | | | | - Samuel Giordano
- Department of Gastroenterology, Cooper University Hospital, Camden, NJ
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Vlismas LJ, Wu W, Ho V. Idiopathic Slow Transit Constipation: Pathophysiology, Diagnosis, and Management. Medicina (Kaunas) 2024; 60:108. [PMID: 38256369 PMCID: PMC10819559 DOI: 10.3390/medicina60010108] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Slow transit constipation (STC) has an estimated prevalence of 2-4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.
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Affiliation(s)
- Luke J. Vlismas
- Deptartment of Gastroenterology, Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (W.W.); (V.H.)
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
| | - William Wu
- Deptartment of Gastroenterology, Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (W.W.); (V.H.)
- School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia
| | - Vincent Ho
- Deptartment of Gastroenterology, Campbelltown Hospital, Campbelltown, NSW 2560, Australia; (W.W.); (V.H.)
- School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia
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Kolachana S, Motwani K, Sakiani S. Gastrointestinal Hemorrhage and Diffuse Bowel Dilation in Huntington Disease. ACG Case Rep J 2024; 11:e01255. [PMID: 38179262 PMCID: PMC10766219 DOI: 10.14309/crj.0000000000001255] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
Huntington disease (HD) is a neurodegenerative condition associated with pathologic involvement beyond the striatum including involvement of the autonomic nervous system. Bowel dysfunction is found in patients with HD, but the exact mechanism is poorly understood and not well reported. Patients may be affected with problems such as dysphagia, weight loss, nutritional deficiencies, esophagitis, and gastritis. Lower bowel symptoms are more prevalent with longer disease course. We present a case of a patient with late-stage HD who presents with severe esophagitis causing gastrointestinal hemorrhage, significant dysmotility including chronic dysphagia requiring gastrostomy tube, and chronic small bowel and colonic ileus.
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Affiliation(s)
- Sindhura Kolachana
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD
| | - Kiran Motwani
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Sasan Sakiani
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD
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5
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Davis TA, Miller A, Hachem C, Velez C, Patel D. The current state of gastrointestinal motility evaluation in cystic fibrosis: a comprehensive literature review. Transl Gastroenterol Hepatol 2023; 9:10. [PMID: 38317748 PMCID: PMC10838618 DOI: 10.21037/tgh-23-59] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/11/2023] [Indexed: 02/07/2024] Open
Abstract
Background and Objective As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential. Methods A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data. Key Content and Findings Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided. Conclusions The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.
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Affiliation(s)
- Trevor A. Davis
- Division of Gastroenterology, Department of Pediatrics, Washington University School of Medicine, Saint Louis Children’s Hospital, St. Louis, MO, USA
| | - Abra Miller
- Division of Gastroenterology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO, USA
| | - Christine Hachem
- Division of Gastroenterology, Department of Medicine, Saint Louis University School of Medicine, University Hospital, St. Louis, MO, USA
| | - Christopher Velez
- Division of Gastroenterology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Dhiren Patel
- Division of Gastroenterology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO, USA
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Chanpong A, Alves MM, Bonora E, De Giorgio R, Thapar N. Evaluating the molecular and genetic mechanisms underlying gut motility disorders. Expert Rev Gastroenterol Hepatol 2023; 17:1301-1312. [PMID: 38117595 DOI: 10.1080/17474124.2023.2296558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 12/14/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Gastrointestinal (GI) motility disorders comprise a wide range of different diseases affecting the structural or functional integrity of the GI neuromusculature. Their clinical presentation and burden of disease depends on the predominant location and extent of gut involvement as well as the component of the gut neuromusculature affected. AREAS COVERED A comprehensive literature review was conducted using the PubMed and Medline databases to identify articles related to GI motility and functional disorders, published between 2016 and 2023. In this article, we highlight the current knowledge of molecular and genetic mechanisms underlying GI dysmotility, including disorders of gut-brain interaction, which involve both GI motor and sensory disturbance. EXPERT OPINION Although the pathophysiology and molecular mechanisms underlying many such disorders remain unclear, recent advances in the assessment of intestinal tissue samples, genetic testing with the application of 'omics' technologies and the use of animal models will provide better insights into disease pathogenesis as well as opportunities to improve therapy.
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Affiliation(s)
- Atchariya Chanpong
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Neurogastroenterology & Motility Unit, Gastroenterology Department, Great Ormond Street Hospital for Children, London, UK
| | - Maria M Alves
- Department of Clinical Genetics, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elena Bonora
- Department of Medical and Surgical Sciences, DIMEC, University of Bologna, Bologna, Italy
- U.O. Genetica Medica, IRCCS Azienda Ospedaliero-Universitaria di Bologna, AOUB, Bologna, Italy
| | - Roberto De Giorgio
- Department of Translational Sciences, University of Ferrara, Ferrara, Italy
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
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Tkachuk B, Collins R, Stukalin I, Gupta M, Ng D, Jijon H. Diffuse Jejunal Lipomatosis and Associated Complications. ACG Case Rep J 2023; 10:e01179. [PMID: 37860810 PMCID: PMC10584287 DOI: 10.14309/crj.0000000000001179] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/19/2023] [Indexed: 10/21/2023] Open
Abstract
Small intestinal lipomatosis is a rare condition with a poorly understood epidemiology and pathophysiology. Cases of small intestinal lipomatosis have been documented in multiple countries over the last century, yet little has been published regarding the natural history of this disease. Therapeutic options are largely surgical and based on limited evidence. We report a unique case of diffuse jejunal lipomatosis in a 62-year-old man with complications of small bowel obstruction, small bowel volvulus, jejunal diverticulosis, pneumatosis intestinalis, malnutrition, small intestinal bacterial overgrowth, and intestinal dysmotility developing over a 12-year period.
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Affiliation(s)
- Bryce Tkachuk
- Division of Internal Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | | | - Igor Stukalin
- Division of Internal Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Milli Gupta
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Danny Ng
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Humberto Jijon
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Canada
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Boris JR, Bernadzikowski T. Emergency Department utilisation and diagnoses in adolescents with postural orthostatic tachycardia syndrome. Cardiol Young 2023; 33:1765-1768. [PMID: 36997316 DOI: 10.1017/s1047951123000707] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Data for Emergency Department utilisation and diagnoses in adolescents with postural orthostatic tachycardia syndrome are lacking, making prevention of these visits more difficult to achieve. MATERIALS AND METHODS We performed a retrospective study of patients with postural orthostatic tachycardia syndrome between ages 12 and 18 years seen in the Emergency Department at a large tertiary care children's hospital. These subjects were age- and sex-matched with controls, with volume of primary and total diagnoses assessed. Due to the relatively small number of subjects, a ± 3-year variance was used among control patients for age matching. RESULTS A total of 297 patients in each group were evaluated. The percentage of female patients was 80.5%. The median age of the subjects was 15.1 years (interquartile range 14.1-15.9), and the median age of controls was 16.1 years (interquartile range 14.4-17.4) (p < 0.00001). Patients with postural orthostatic tachycardia syndrome had greater gastroenterologic and headache diagnoses (p < 0.00001); controls had greater autonomic and psychiatric diagnoses. DISCUSSION Adolescent patients with postural orthostatic tachycardia syndrome who present to the Emergency Department have a preponderance of gastroenterologic and headache complaints versus controls.
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9
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Zhang M, Morice AH. Unravelling vagal hypersensitivity in chronic cough: A distinct disease. J Physiol 2023. [PMID: 37642341 DOI: 10.1113/jp284641] [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: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
Chronic cough (CC) is a common but poorly understood disease that has a negative impact on quality of life. For years, clinicians have been trying to find the underlying diagnosis and using existing disease models to describe the patients' illness. This presents a confusing picture of CC. Most patients with CC present with hypersensitivity of the cough reflex, which is characterised by laryngeal paraesthesia and an increased response to the tussive stimuli or an innocuous stimulus that would not trigger coughing in healthy people. Recently, it has been proposed that CC is a unique disease characterised by vagal hypersensitivity that projects to the central nervous system altering responsiveness. The evidence supports the hypothesis that CC is primarily a neurological disorder, consisting of different phenotypes.
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Affiliation(s)
- Mengru Zhang
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
- Centre for Clinical Science, Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
| | - Alyn H Morice
- Centre for Clinical Science, Respiratory Medicine, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
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10
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Yule A, Sills D, Smith S, Spiller R, Smyth AR. Thinking outside the box: a review of gastrointestinal symptoms and complications in cystic fibrosis. Expert Rev Respir Med 2023; 17:547-561. [PMID: 37345513 DOI: 10.1080/17476348.2023.2228194] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Gastrointestinal (GI)-related symptoms, complications, and comorbidities in cystic fibrosis (CF) are common and research to reduce their burden is a priority for the CF community. To enable future research, this review aimed to summarize the range of GI symptoms, complications and comorbidities seen in CF, the underlying pathophysiology, and treatments. AREAS COVERED This was a rapid systematic review undertaken using the recommendations from the Cochrane Rapid Reviews Methods Group. We searched databases including PubMed, Embase, Medline and the Cochrane database and identified those studies reporting GI-related symptoms, complications, or comorbidities in CF or their treatment. Our searches identified 2,930 studies and a total 119 studies met our inclusion criteria. Where a prevalence could be determined, GI symptoms were reported in 33.7% of study participants. The range of symptoms reported was broad and the highest median prevalence included flatulence (43.5%), bloating and abdominal distension (36%), and fatty stool (36%). Meconium ileus was reported in 12% and distal intestinal obstruction syndrome in 8.5. EXPERT OPINION GI-related symptoms, complications, and comorbidities in CF are common. More consistent characterization and recording of these symptoms in clinical studies may help achieve the priority of reducing the burden of GI disease in CF.
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Affiliation(s)
- Alexander Yule
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
| | - Darren Sills
- Nutrition and Dietetics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sherie Smith
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robin Spiller
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
- Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan R Smyth
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
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Patel D, Khodadadi A, Jadcherla A, Rengarajan A, Rogers BD, Gyawali CP. Chronic opioid users with dysphagia are indistinguishable from symptomatic nonusers on functional lumen imaging probe evaluation. Neurogastroenterol Motil 2022; 35:e14519. [PMID: 36578248 DOI: 10.1111/nmo.14519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Opioid-induced esophageal dysmotility (OIED) includes spastic esophageal motility disorders, increasingly recognized in the contemporary opioid epidemic. We assessed functional lumen imaging probe (FLIP) findings in diagnosing OIED. METHODS Symptomatic patients undergoing FLIP with no prior foregut surgery who completed validated questionnaires were identified and segregated into chronic opioid users and nonusers in this cohort study. Esophagogastric junction (EGJ) distensibility index (DI), EGJ diameter, and esophageal body contraction patterns were extracted. Symptom profiles were compared to FLIP findings between chronic opioid users and nonusers. Outcome was evaluated in a subset using the same validated questionnaires. RESULTS Over the 18-months study period, of 116 patients (median age 62 years, 70.7% female), 33 (28.4%) were chronic opioid users, with median morphine milligram equivalent of 30 mg. While presenting symptoms were similar, chronic opioid users reported higher perceptive symptoms (p = 0.008) and worse quality of life (p = 0.01) compared to nonusers. Median DI trended lower in chronic opioid users (p = 0.08), with more retrograde repetitive contractions (p < 0.001) and less absent contractility (p = 0.007), but final FLIP diagnoses were similar compared to nonusers. There was no correlation between opioid dose and FLIP metrics. In the subset with follow-up, perceptive symptoms trended higher in chronic opioid users (p = 0.08), but symptom improvement following therapy was similar in both groups. CONCLUSIONS & INFERENCES Symptomatic chronic opioid users have FLIP diagnoses that are similar to nonusers, despite higher perceptive symptoms and worse quality of life. Dominant symptoms improve both in chronic opioid users and nonusers following treatment directed by FLIP.
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Affiliation(s)
- Devan Patel
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Alexandra Khodadadi
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Aditya Jadcherla
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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Langford JS, Tokita E, Martindale C, Millsap L, Hemp J, Pace LA, Cortez MM. Quantitative gastrointestinal function and corresponding symptom profiles in autonomic neuropathy. Front Neurol 2022; 13:1027348. [PMID: 36588909 PMCID: PMC9798202 DOI: 10.3389/fneur.2022.1027348] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Peripheral neuropathies with autonomic nervous system involvement are a recognized cause of gastrointestinal dysmotility for a wide spectrum of diseases. Recent advances in wireless motility capsule testing allow improved sampling of regional and whole gut motility to aid in the diagnosis of gastrointestinal motility disorders and may provide additional insight into segment-specific enteric involvement of peripheral neuropathies affecting autonomic nervous system function. Methods We utilized standardized autonomic nervous system (ANS) reflex assessment and wireless motility capsule testing to evaluate 20 individuals with idiopathic autonomic neuropathy and unexplained gastrointestinal symptoms. Additionally, we examined the relationship between quantifiable autonomic neuropathy and gastrointestinal dysmotility at specific neuroanatomical levels. Symptom profiles were evaluated using the 31-item Composite Autonomic Symptom Score questionnaire (COMPASS-31) and compared to wireless motility capsule data. Results We found that transit times were predominately abnormal (delayed) in the foregut (10 of 20; 50%), while contractility abnormalities were far more prominent in the hindgut (17 of 20; 85%), and that motility and symptom patterns, as assessed by the COMPASS-31 GI domain items, generally corresponded. Finally, we also found that there was neuroanatomical overlap in the presence of autonomic reflex abnormalities and WMC-based transit and/or contractility abnormalities. Conclusions We found that transit times were predominately abnormal in the foregut and midgut, while contractility abnormalities were far more prominent in the hindgut in individuals with idiopathic autonomic neuropathy. There was a high rate of agreement in segmental wireless motility capsule data with neuroanatomically corresponding standardized ANS function measures (e.g., cardiovagal, sudomotor, adrenergic). Expanded sudomotor testing, including additional neuroanatomical segments, could provide additional indirect assessment of visceral involvement in ANS dysfunction.
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Affiliation(s)
- Jordan S. Langford
- University of Utah School of Medicine, University of Utah, Salt Lake City, UT, United States,*Correspondence: Jordan S. Langford
| | - Eric Tokita
- University of Utah School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Cecilia Martindale
- Department of Neurology, Imaging and Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Leah Millsap
- University of Utah School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - James Hemp
- Metrodora Institute, West Valley City, UT, United States
| | - Laura A. Pace
- Metrodora Institute, West Valley City, UT, United States
| | - Melissa M. Cortez
- Department of Neurology, Imaging and Neurosciences Center, University of Utah, Salt Lake City, UT, United States,Melissa M. Cortez
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Adler B, Hummers LK, Pasricha PJ, McMahan ZH. Gastroparesis in systemic sclerosis: a detailed analysis using whole-gut scintigraphy. Rheumatology (Oxford) 2022; 61:4503-4508. [PMID: 35136977 PMCID: PMC9629369 DOI: 10.1093/rheumatology/keac074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Gastroparesis is a common complication of SSc. We sought to determine the degree of overlap between gastroparesis and dysmotility in other areas of the gut, correlate our findings with gastrointestinal (GI) symptoms, and examine associations between gastroparesis and SSc features. METHODS Whole-gut scintigraphy was performed on SSc patients who were enrolled in the Johns Hopkins Scleroderma Cohort, for whom detailed longitudinal clinical and serologic data are collected. A subset of patients completed the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0) to quantify their GI symptoms. We examined associations between the presence and severity of gastroparesis, GI symptoms, and SSc clinical features. RESULTS Ninety-seven SSc patients with and without GI symptoms underwent whole-gut scintigraphy and completed the gastric emptying study. Of the 97, 34 (35%) met criteria for gastroparesis. Of the measures assessed, delayed liquid emptying captured more patients with delayed gastric transit than delayed solid emptying (74% vs 55%), and percentage liquid emptying correlated best with GIT Reflux (ρ = -0.33, P = 0.01) and Distension (ρ = -0.30, P = 0.03) scores. Of 33 patients with gastroparesis, 30 (91%) had abnormal transit in other areas of the GI tract. Higher anti-centromere protein B (CENP-B) titres correlated with slower gastric emptying (ρ = -0.26, P = 0.03), but no specific clinical features of SSc were associated with gastroparesis. CONCLUSIONS Gastric emptying of liquids when given alongside solids may be more sensitive and provide a more clinically relevant measure of gastroparesis in SSc than solid gastric emptying or liquid gastric emptying alone. SSc patients with gastroparesis frequently have dysmotility in other areas of the GI tract, underscoring the need for whole-gut scintigraphy to evaluate the entire gut.
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Affiliation(s)
| | | | - P Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
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Gollifer RM, Taylor SA, Menys A, Zarate‐Lopez N, Chatoor D, Emmanuel A, Atkinson D. Magnetic resonance imaging assessed enteric motility and luminal content analysis in patients with severe bloating and visible distension. Neurogastroenterol Motil 2022; 34:e14381. [PMID: 35438218 PMCID: PMC9786248 DOI: 10.1111/nmo.14381] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 02/22/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Gastrointestinal symptoms in functional gut disorders occur without any discernible structural gut abnormality. Preliminary observations on enteric MRI suggest possible abnormal content and motility of the terminal ileum (TI) in constipation-predominant IBS (IBS-C) with severe bloating, and in functional bloating and distension (FABD) patients. We investigated whether MRI can quantify differences in small bowel (SB) content and motility between patients and healthy controls (HCs). METHODS 11 IBS-C (mean age 40 [21-52] years; 10 women) and 7 FABD (36 [21-56]; all women) patients with bloating and 20 HCs (28 [22-48]; 6 women) underwent enteric MRI, including dynamic motility and anatomical sequences. Three texture analysis (TA) parameters assessed the homogeneity of the luminal content, with ratios calculated between the TI and (1) the SB and (2) the ascending colon. Four TI motility metrics were derived. Ascending colon diameter (ACD) was measured. A comparison between HCs and patients was performed independently for: (1) three TA parameters, (2) four TI motility metrics, and (3) ACD. KEY RESULTS Compared with HCs, patients had TI:colon ratios higher for TA contrast (p < 0.001), decreased TI motility (lower mean motility [p = 0.04], spatial motility variation [p = 0.03], and area of motile TI [p = 0.03]), and increased ACD (p = 0.001). CONCLUSIONS AND INFERENCES IBS-C and FABD patients show reduced TI motility and differences in luminal content compared with HCs. This potentially indicates reflux of colonic contents or delayed clearance of the TI, which alongside increased ACD may contribute to symptoms of constipation and bloating.
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Affiliation(s)
| | - Stuart A. Taylor
- Centre for Medical ImagingUniversity College London (UCL)LondonUK
| | - Alex Menys
- Centre for Medical ImagingUniversity College London (UCL)LondonUK
| | | | - Dave Chatoor
- Department of GastroenterologyUniversity College London HospitalsLondonUK
| | - Anton Emmanuel
- Department of GastroenterologyUniversity College London HospitalsLondonUK
| | - David Atkinson
- Centre for Medical ImagingUniversity College London (UCL)LondonUK
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Zheng T, BouSaba J, Sannaa W, Eckert DJ, Burton DD, Camilleri M. Comprehensive characterization of antral and pyloric contractions by high resolution manometry: applied physiology in suspected gastroparesis. Am J Physiol Gastrointest Liver Physiol 2022; 323:G255-G264. [PMID: 35819155 PMCID: PMC9448275 DOI: 10.1152/ajpgi.00119.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 05/05/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 02/03/2023]
Abstract
Delayed gastric emptying may result from diverse pathophysiological mechanisms including antral hypomotility and pylorospasm. With increasing use of gastric peroral endoscopic myotomy and preliminary evidence of efficacy, our aim was to assess the motor functions of the distal antrum and pylorus in patients with symptoms of gastroparesis using high-resolution antropyloroduodenal manometry (HR-ADM). Sixteen patients with symptoms suggestive of gastroparesis underwent HR-ADM with 13 sensors, 1 cm apart, placed across the antropyloroduodenal (APD) junction and 2 sensors, 10 cm apart, in descending and distal duodenum. The 1-h postprandial motility was quantitated as contraction frequency/minute, average amplitude, and motility index (MI). Six healthy volunteers served as controls. In the patient group, the HR-ADM identified postprandial antral hypomotility, isolated pyloric pressure waves, and tonic elevation of baseline pressure in pylorus. Patients had significantly reduced frequency of the full-hour postprandial antral contractions/minute compared with healthy volunteers [1.52 (0.97, 1.67) vs. 2.04 (1.70, 2.67), P = 0.005], as well as reduced MI [9.65 (8.29, 10.31) vs. 11.04 (10.65, 11.63), P = 0.002]. The average contraction amplitude was numerically, but not significantly reduced [51.9 (21.9, 74.9) vs. 73.0 (59.8, 82.7), P = 0.14]. Bland-Altman plots showed similar distribution of antral contraction frequency and MI during the first and second postprandial 30-min periods for both patients and controls. High-resolution ADM can characterize a variety of postprandial antral contractile and pyloric motility dysfunctions. This technique shows promise to provide guidance for the selection of optimal treatment of patients with gastroparesis.NEW & NOTEWORTHY Current selection of different treatments for patients with gastroparesis is empiric or based on trial and error, though pyloric distensibility and diameter may predict response to pyloric interventions. High-resolution antropyloroduodenal manometry (HR-ADM) can characterize a variety of postprandial antral contractile and pyloric motility dysfunctions in patients with suspected gastroparesis. HR-ADM shows promise to provide guidance for selection and individualization of treatments such as prokinetic agents or pyloric interventions for patients with gastroparesis based on documented pathophysiology.
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Affiliation(s)
- Ting Zheng
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Joelle BouSaba
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Wassel Sannaa
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Deborah J Eckert
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Duane D Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Sandy NS, Huysentruyt K, Mulder DJ, Warner N, Chong K, Morel C, AlQahtani S, Wales PW, Martin MG, Muise AM, Avitzur Y. The Diverse Phenotype of Intestinal Dysmotility Secondary to ACTG2-related Disorders. J Pediatr Gastroenterol Nutr 2022; 74:575-581. [PMID: 35149643 PMCID: PMC9632465 DOI: 10.1097/mpg.0000000000003400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The initial description of a heterozygous dominant ACTG2 variant in familial visceral myopathy was followed by the identification of additional variants in other forms of intestinal dysmotility disorders. we aimed to describe the diverse phenotype of this newly reported and rare disease. METHODS Report of 4 new patients, and a systematic review of ACTG2-related disorders. we analyzed the population frequency and used in silico gene damaging predictions. Genotype-phenotype correlations were explored. RESULTS One hundred three patients (52% girls), from 14 publications, were included. Twenty-eight unique variants were analyzed, all exceedingly rare, and 27 predicted to be highly damaging. The median Combined Annotation Dependent Depletion (CADD) score was 29.2 (Interquartile range 26.3-29.4). Most patients underwent abdominal surgery (66%), about half required intermittent bladder catheterization (48.5%), and more than half were parenteral nutrition (PN)-dependent (53%). One-quarter of the patients died (25.7%), and 6 required transplant (5.8%). Girls had a higher rate of microcolon (P = 0.009), PN dependency (P = 0.003), and death/transplant (P = 0.029) compared with boys, and early disease onset (<2 years of age) was associated with megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) features. There was no statistical association between disease characteristics and CADD scores. CONCLUSIONS Damaging ACTG2 variants are rare, often associated with MMIHS phenotype, and overall have a wide phenotypic variation. Symptoms usually present in the perinatal period but can also appear at a later age. The course of the disease is marked by frequent need for surgical interventions, PN support, and mortality. Poor outcomes are more common among girls with ACTG2 variants.
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Affiliation(s)
- Natascha S. Sandy
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Koen Huysentruyt
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, vrije Universiteit Brussel (vUB), Brussels, Belgium
| | - Daniel J. Mulder
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Neil Warner
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen Chong
- The Prenatal Diagnosis and Medical Genetics Program. Mount Sinai Hospital, Toronto, ON
| | - Chantal Morel
- Cancer Clinical Research Unit (CCRU), Princess Margaret Cancer Centre, The Hospital for Sick Children, University ofToronto, Toronto, Ontario, Canada
| | - Saleh AlQahtani
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of general and thoracic Surgery, The Hospital for Sick Children, University ofToronto, Toronto, Ontario, Canada
| | - Martin G. Martin
- # Division of Gastroenterology and Nutrition, Department of Pediatrics, Mattel Children’s Hospital and the David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Aleixo M. Muise
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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17
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Almeida PP, Valdetaro L, Thomasi BBDM, Stockler-Pinto MB, Tavares-Gomes AL. High-fat diets on the enteric nervous system: Possible interactions and mechanisms underlying dysmotility. Obes Rev 2022; 23:e13404. [PMID: 34873814 DOI: 10.1111/obr.13404] [Citation(s) in RCA: 4] [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: 08/30/2021] [Revised: 10/25/2021] [Accepted: 11/15/2021] [Indexed: 01/09/2023]
Abstract
Obesity is a chronic disease that affects various physiological systems. Among them, the gastrointestinal tract appears to be a main target of this disease. High-fat diet (HFD) animal models can help recapitulate the classic signs of obesity and present a series of gastrointestinal alterations, mainly dysmotility. Because intestinal motility is governed by the enteric nervous system (ENS), enteric neurons, and glial cells have been studied in HFD models. Given the importance of the ENS in general gut physiology, this review aims to discuss the relationship between HFD-induced neuroplasticity and gut dysmotility observed in experimental models. Furthermore, we highlight components of the gut environment that might influence enteric neuroplasticity, including gut microbiota, enteric glio-epithelial unit, serotonin release, immune cells, and disturbances such as inflammation and oxidative stress.
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Affiliation(s)
| | - Luisa Valdetaro
- Postgraduate Program in Neurosciences, Fluminense Federal University, Niterói, Brazil
| | | | - Milena Barcza Stockler-Pinto
- Postgraduate Program in Cardiovascular Sciences, Fluminense Federal University, Niterói, Brazil.,Postgraduate Program in Nutrition Sciences, Fluminense Federal University, Niterói, Brazil
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18
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Rosen R, Stayn Z, Garza JM, DiFilippo C, Cohen A, Kane M, Wall S, Nurko S. The Utility of Functional Luminal Imaging Probes Measurements to Diagnose Dysmotility and Their Relationship to Impaired Bolus Clearance. J Pediatr Gastroenterol Nutr 2022; 74:523-528. [PMID: 35129159 PMCID: PMC10326850 DOI: 10.1097/mpg.0000000000003394] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Indexed: 12/10/2022]
Abstract
BACKGROUND Functional luminal imaging probes (FLIP) have been used by multiple centers to assess esophagogastric junction (EGJ) function in patients at risk for esophageal obstruction but its role in diagnosing peristaltic disorders is less well studied. In particular, there are no studies comparing the sensitivity of FLIP to diagnose motility abnormalities and impaired bolus transit by high-resolution esophageal manometry with impedance. METHODS We prospectively recruited 42 patients undergoing high-resolution esophageal manometry with impedance (HRIM) who also underwent FLIP between 2018 and 2020. HRIM parameters were analyzed using Swallow Gateway software to determine peristaltic and lower esophageal sphincter pressure measurements as well as bolus flow parameters. FLIP tracings were analyzed for the presence of repetitive antegrade contractions (RACs), EGJ distensibility, and associated parameters. RESULTS Forty-two patients were included (11 controls, 7 achalasia, 16 fundoplication, 8 dysmotility). The mean age of patients was 10.1 ± 0.9 years. There were significant differences in bolus flow parameters across diagnosis with longer bolus presence (BPT) in control patients compared with fundoplication and dysmotility patients. There was a significant correlation between EGJ diameter, EGJ distensibility and bolus flow time (BFT) for solid foods (r2 > 0.518, P < 0.02). The presence of RACs and EGJ relaxation during RACs was associated with a greater BFT and BPT across textures (P < 0.05). Forty-two percentage of patients with absent RACs, however, had clear peristalsis by HRIM. CONCLUSIONS The presence of RACs and EGJ relaxation by FLIP correlate with improved bolus flow. Patients with an absence of RACs need HRIM to confirm any diagnoses of dysmotility.
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Affiliation(s)
- Rachel Rosen
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
| | - Zachary Stayn
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
| | - Jose M. Garza
- GI Cares for Kids, Atlanta, GA Neurogastroenterology and Motility Program Children’s Healthcare of Atlanta, Atlanta, GA
| | - Courtney DiFilippo
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
| | - Alexandra Cohen
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
| | - Madeline Kane
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
| | - Stephanie Wall
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology & Nutrition, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Boston, MA
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19
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Yasuda JL, Staffa SJ, Nurko S, Kane M, Wall S, Mougey EB, Franciosi JP, Manfredi MA, Rosen R. Pharmacogenomics fail to explain proton pump inhibitor refractory esophagitis in pediatric esophageal atresia. Neurogastroenterol Motil 2022; 34:e14217. [PMID: 34337835 DOI: 10.1111/nmo.14217] [Citation(s) in RCA: 4] [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: 12/22/2020] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Esophagitis is prevalent in patients with esophageal dysmotility despite acid suppression, likely related to poor esophageal clearance. Esophageal atresia (EA) is a classic model of dysmotility where this observation holds true. In adult non-dysmotility populations, failure of esophagitis to respond to proton pump inhibitors (PPI) has been linked to variants in CYP2C19 that influence the activity of the encoded enzyme. It is unknown if CYP2C19 metabolizer phenotype contributes to PPI-refractory, non-allergic esophagitis in EA. METHODS We performed a cross-sectional study of 314 children with (N = 188) and without (N = 126) EA who were on PPI therapy at the time of endoscopy to evaluate for possible gastroesophageal reflux disease. Patients with eosinophilic esophagitis and/or fundoplication were excluded. Clinical and histology data were collected. Genomic DNA from biopsy samples was genotyped for polymorphisms in CYP2C19. RESULTS CYP2C19 metabolizer phenotypes were not associated with presence or severity of esophagitis (P = 0.994). In a multivariate logistic regression adjusted for potential confounders, EA was the strongest and only significant predictor of esophagitis (odds ratio 2.72, P = 0.023). Using negative binomial regression, we found that CYP2C19 phenotype was not a significant predictor of eosinophil count in children with PPI-refractory esophagitis. CONCLUSIONS Patients with EA are significantly more likely to experience PPI-refractory, non-allergic esophagitis than controls regardless of CYP2C19 metabolizer phenotype, suggesting that factors other than CYP2C19 genetics, including dysmotility, are the primary drivers of esophagitis in EA. CYP2C19 genotype failed to predict PPI-refractory, non-allergic esophagitis in both EA and non-EA children.
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Affiliation(s)
- Jessica L Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Madeline Kane
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Stephanie Wall
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Edward B Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| | - James P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, FL, USA.,Department of Pediatrics, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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20
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Vayzband V, Ashraf H, Esparragoza P. Surgically Managed Perforated Jejunal Diverticulitis. Cureus 2021; 13:e15930. [PMID: 34336432 PMCID: PMC8313005 DOI: 10.7759/cureus.15930] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2021] [Indexed: 11/26/2022] Open
Abstract
A 71-year-old male with a past medical history significant for chronic constipation presented to the emergency department for acute onset of severe abdominal pain. On presentation, the patient appeared to be in distress, exemplifying signs of peritonitis despite vital signs being grossly benign. CT scan established the diagnosis of a perforated jejunal diverticulitis. Initially, the patient was managed conservatively with IV fluids, antibiotics, and pain control medications. Diagnostic imaging in tandem with the patient's failure to improve incited surgical intervention with a jejunal resection and establishment of a primary anastomosis. This case illustrates additional differential diagnoses necessary for consideration in an elderly patient presenting with an acute abdomen.
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Affiliation(s)
- Vlad Vayzband
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Hamza Ashraf
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Paola Esparragoza
- Gastroenterology and Hepatology, Saint Peter's University Hospital, New Brunswick, USA
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21
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Henen S, Denton C, Teckman J, Borowitz D, Patel D. Review of Gastrointestinal Motility in Cystic Fibrosis. J Cyst Fibros 2021; 20:578-585. [PMID: 34147362 DOI: 10.1016/j.jcf.2021.05.016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Gastrointestinal manifestations in patients with cystic fibrosis (CF) are extremely common and have recently become a research focus. Gastrointestinal (GI) dysfunction is poorly understood in the CF population, despite many speculations including the role of luminal pH, bacterial overgrowth, and abnormal microbiome. Nevertheless, dysmotility is emerging as a possible key player in CF intestinal symptoms. Our review article aims to explore the sequelae of defective cystic fibrosis transmembrane conductance regulator (CFTR) genes on the GI tract as studied in both animals and humans, describe various presentations of intestinal dysmotility in CF, review newer diagnostic motility techniques including intraluminal manometry, and review the current literature regarding the potential role of dysmotility in CF-related intestinal pathologies.
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Affiliation(s)
- Sara Henen
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104.
| | - Christine Denton
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104
| | - Jeff Teckman
- Interim Chair, Department of Pediatrics, Professor of Pediatrics and Biochemistry, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand BLVD, St. Louis, MO 63104.
| | - Drucy Borowitz
- Emeritus Professor of Clinical Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY, 1001 Main Street, Buffalo, NY, 14203.
| | - Dhiren Patel
- Associate Professor and Medical Director, Neurogastroenterology and Motility Program, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St. Louis, MO 63104.
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22
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Radetic M, Kamal A, Rouphael C, Kou L, Lyu R, Cline M. Severe gastroparesis is associated with an increased incidence of slow-transit constipation as measured by wireless motility capsule. Neurogastroenterol Motil 2021; 33:e14045. [PMID: 33231369 DOI: 10.1111/nmo.14045] [Citation(s) in RCA: 3] [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: 02/08/2020] [Revised: 10/21/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dysmotility in one region of the gastrointestinal tract has been found to predispose patients to developing motility disorders in other gastrointestinal segments. However, few studies have evaluated the relationship between gastroparesis and constipation. METHODS Retrospective review of 224 patients who completed 4-hour, solid-phase gastric emptying scintigraphy (GES), and wireless motility capsule (WMC) testing to evaluate for gastroparesis and slow-transit constipation, respectively. When available, anorectal manometry data were reviewed to evaluate for dyssynergic defecation. Patients were divided into two groups based on the results of the GES: 101 patients with normal gastric emptying and 123 patients with gastroparesis (stratified by severity). Differences in constipation rates were compared between the groups. KEY RESULTS Slow-transit constipation was more common in the gastroparesis group, but statistical significance was not reached (42.3% vs 34.7%, p = 0.304). Univariate logistical regression analysis found no association between slow-transit constipation and gastroparesis (OR 1.38, 95% CI 0.80-2.38, p = 0.245) nor dyssynergic defecation and gastroparesis (OR 0.88, 95% CI 0.29-2.70, p = 0.822). However, when stratifying gastroparesis based on severity, slow-transit constipation was found to be associated with severe gastroparesis (OR 2.45, 95% CI 1.20-5.00, p = 0.014). This association was strengthened with the exclusion of patients with diabetes mellitus (OR 3.5, 95% CI 1.39-8.83, p = 0.008) - a potential confounder. CONCLUSIONS & INFERENCES Patients with severe gastroparesis (>35% gastric retention at the 4-hour mark on solid-phase GES) have an increased likelihood of having underlying slow-transit constipation. Dyssynergic defecation does not appear to be associated with gastroparesis (of any severity).
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Affiliation(s)
- Mark Radetic
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University, Redwood City, CA, USA
| | - Carol Rouphael
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Lei Kou
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael Cline
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
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Ayari M, Nakhli A, Teyeb Z, Abdelaali I, Bellakhal S, Jomni T. Intestinal pseudo-obstruction: Unusual presentation of systemic lupus erythematous. Clin Case Rep 2021; 9:1759-1762. [PMID: 33768930 PMCID: PMC7981693 DOI: 10.1002/ccr3.3907] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 12/08/2020] [Accepted: 01/21/2021] [Indexed: 11/30/2022] Open
Abstract
Systemic diseases should be always considered when managing unexplained intestinal pseudo-obstruction. Intestinal pseudo-obstruction related to systemic lupus erythematosus is often responsive to corticosteroid therapy when promptly treated.
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Affiliation(s)
- Myriam Ayari
- Gastroenterology UnitInternal Medicine DepartmentLa Marsa Internal Security Forces HospitalTunisTunisia
| | - Abdelwaheb Nakhli
- Gastroenterology UnitInternal Medicine DepartmentLa Marsa Internal Security Forces HospitalTunisTunisia
| | - Zeineb Teyeb
- Gastroenterology UnitInternal Medicine DepartmentLa Marsa Internal Security Forces HospitalTunisTunisia
| | - Imen Abdelaali
- Gastroenterology UnitInternal Medicine DepartmentLa Marsa Internal Security Forces HospitalTunisTunisia
| | - Syrine Bellakhal
- Gastroenterology UnitInternal Medicine DepartmentLa Marsa Internal Security Forces HospitalTunisTunisia
| | - Taieb Jomni
- Gastroenterology UnitInternal Medicine DepartmentLa Marsa Internal Security Forces HospitalTunisTunisia
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Kido M, Kuwahara T, Yasui Y, Okajima H, Kohno M. Hypertrophic pyloric stenosis at birth: A case report. Pediatr Int 2021; 63:231-233. [PMID: 33629427 DOI: 10.1111/ped.14392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Miori Kido
- Department of Pediatric Surgery, Kanazawa Medical University, Kahoku, Ishikawa, Japan
| | - Tsuyoshi Kuwahara
- Department of Pediatric Surgery, Kanazawa Medical University, Kahoku, Ishikawa, Japan
| | - Yoshitomo Yasui
- Department of Pediatric Surgery, Kanazawa Medical University, Kahoku, Ishikawa, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Kahoku, Ishikawa, Japan
| | - Miyuki Kohno
- Department of Pediatric Surgery, Kanazawa Medical University, Kahoku, Ishikawa, Japan
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Elfar W, Gurjar AA, Talukder MAH, Noble M, Di Lorenzo C, Elfar J. Erythropoietin promotes functional recovery in a mouse model of postoperative ileus. Neurogastroenterol Motil 2021; 33:e14049. [PMID: 33368893 DOI: 10.1111/nmo.14049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/16/2019] [Revised: 07/27/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dysmotility and postoperative ileus (POI) are major clinical problems after surgical trauma and it is associated with increased intestinal inflammation and oxidative stress. Despite the high occurrence of POI following intra-abdominal surgeries, no effective treatment is currently available. Erythropoietin (EPO) is a multifunctional tissue-protective cytokine with potent anti-inflammatory and anti-oxidative properties, and it is an FDA approved medicine for clinical use. While both EPO and EPO receptors (EPOR) are widely expressed in the gut, the role of EPO in POI is largely unknown. This study was designed to explore the possible beneficial effect of EPO in a mouse model of POI. METHODS Mice were subjected to intestinal manipulation to induce standard POI and intestinal transit time was determined at 24-h post-injury with or without EPO treatment (5000 units/kg, once, IP, immediately after intestinal trauma). Intestinal samples were harvested for histological and immunohistochemical analysis. RESULTS Systemic EPO significantly improved intestinal transit time compared with control group and it was associated with significantly increased levels of tissue macrophages and reduced levels of oxidative stress. CONCLUSIONS AND INFERENCES This is the first pre-clinical study to document novel beneficial effects of EPO in gut dysmotility and our findings suggest that the beneficial effects of EPO in POI is predominantly mediated by its anti-oxidative and immunomodulatory properties.
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Affiliation(s)
- Walaa Elfar
- Division of Gastroenterology and Nutrition, Department of Pediatrics, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Anagha A Gurjar
- Department of Orthopedics and Rehabilitation, Center for Orthopedics and Translational Sciences (CORTS), The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - M A Hassan Talukder
- Department of Orthopedics and Rehabilitation, Center for Orthopedics and Translational Sciences (CORTS), The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Mark Noble
- Department of Biomedical Genetics, University of Rochester Medical Center, Rochester, New York, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - John Elfar
- Department of Orthopedics and Rehabilitation, Center for Orthopedics and Translational Sciences (CORTS), The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Nyavor Y, Brands CR, Nicholson J, Kuther S, Cox KK, May G, Miller C, Yasuda A, Potter F, Cady J, Heyman HM, Metz TO, Stark TD, Hofmann T, Balemba OB. Supernatants of intestinal luminal contents from mice fed high-fat diet impair intestinal motility by injuring enteric neurons and smooth muscle cells. Neurogastroenterol Motil 2021; 33:e13990. [PMID: 32969549 DOI: 10.1111/nmo.13990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/10/2019] [Revised: 08/12/2020] [Accepted: 08/25/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Damage to enteric neurons and impaired gastrointestinal muscle contractions cause motility disorders in 70% of diabetic patients. It is thought that enteric neuropathy and dysmotility occur before overt diabetes, but triggers of these abnormalities are not fully known. We tested the hypothesis that intestinal contents of mice with and without high-fat diet- (HFD-) induced diabetic conditions contain molecules that impair gastrointestinal movements by damaging neurons and disrupting muscle contractions. METHODS Small and large intestinal segments were collected from healthy, standard chow diet (SCD) fed mice. Filtrates of ileocecal contents (ileocecal supernatants; ICS) from HFD or SCD mice were perfused through them. Cultured intact intestinal muscularis externa preparations were used to determine whether ICS and their fractions obtained by solid-phase extraction (SPE) and SPE subfractions collected by high-performance liquid chromatography (HPLC) disrupt muscle contractions by injuring neurons and smooth muscle cells. KEY RESULTS ICS from HFD mice reduced intestinal motility, but those from SCD mice had no effect. ICS, aqueous SPE fractions and two out of twenty HPLC subfractions of aqueous SPE fractions from HFD mice blocked muscle contractions, caused a loss of nitrergic myenteric neurons through inflammation, and reduced smooth muscle excitability. Lipopolysaccharide and palmitate caused a loss of nitrergic myenteric neurons but did not affect muscle contractions. CONCLUSIONS & INFERENCES Unknown molecules in intestinal contents of HFD mice trigger enteric neuropathy and dysmotility. Further studies are required to identify the toxic molecules and their mechanisms of action.
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Affiliation(s)
- Yvonne Nyavor
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | | | - Jessica Nicholson
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | - Sydney Kuther
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | - Kortni K Cox
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | - George May
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | | | - Allysha Yasuda
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | - Forrest Potter
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | - Joshua Cady
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
| | - Heino M Heyman
- Earth and Biological Sciences Directorate, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Thomas O Metz
- Earth and Biological Sciences Directorate, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Timo D Stark
- Lehrstuhl für Lebensmittelchemie und Molekulare Sensorik, Technische Universität München, Freising, Germany
| | - Thomas Hofmann
- Lehrstuhl für Lebensmittelchemie und Molekulare Sensorik, Technische Universität München, Freising, Germany
| | - Onesmo B Balemba
- Department of Biological Sciences, University of Idaho, Moscow, ID, USA
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27
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Lötstedt B, Boyer D, Visner G, Freiberger D, Lurie M, Kane M, DiFilippo C, Lundeberg J, Narvaez-Rivas M, Setchell K, Alm E, Rosen R. The impact of gastrointestinal dysmotility on the aerodigestive microbiome of pediatric lung transplant recipients. J Heart Lung Transplant 2020; 40:210-219. [PMID: 33349521 DOI: 10.1016/j.healun.2020.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/12/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Delayed gastric emptying has been associated with increased graft rejection, although the mechanism of this association is not known. This study aims to investigate the interrelationship between delays in gastrointestinal motility and the diversity and composition of gastric, oropharyngeal, and lung microbiomes in pediatric lung transplant recipients. METHODS We prospectively recruited 23 pediatric lung transplant recipients and 98 pediatric patients with respiratory symptoms undergoing combined endoscopy and bronchoscopy. Gastric, oropharyngeal, and bronchoalveolar lavage samples were collected for 16S sequencing. Gastric samples were also analyzed for bile composition using liquid chromatography. RESULTS Patients who underwent lung transplantation had significantly reduced alpha diversity in gastric and oropharyngeal sites compared with patients with respiratory symptoms. This reduction in alpha diversity was especially evident in gastric samples in patients with delayed gastric emptying defined as abnormal gastric emptying on nuclear scintigraphy or as an elevation in gastric bile concentration (p ≤ 0.05). Whereas monocolonies were seen in the lungs of patients who underwent transplantation, these were not the same microbes seen in the stomach; the microbial overlap between lung and gastric samples within patients was low, and data indicated high individual variation between lung transplant recipients. Other contributors to reduced alpha diversity included antibiotics in combination with proton pump inhibitors, especially in gastric and oropharyngeal samples. CONCLUSIONS Lung transplant recipients have reduced microbial diversity in gastric fluid (GF) and oropharynx compared with patients who did not undergo lung transplantation. The decreased alpha diversity in GF may be associated with dysmotility.
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Affiliation(s)
- Britta Lötstedt
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts; Science for Life Laboratory, Department of Gene Technology, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Debra Boyer
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Dawn Freiberger
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Margot Lurie
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - Madeline Kane
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - Courtney DiFilippo
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - Joakim Lundeberg
- Science for Life Laboratory, Department of Gene Technology, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Monica Narvaez-Rivas
- Division of Gastroenterology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Kenneth Setchell
- Division of Gastroenterology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Eric Alm
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts.
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Rybak A, Sethuraman A, Nikaki K, Koeglmeier J, Lindley K, Borrelli O. Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure. Nutrients 2020; 12:nu12113536. [PMID: 33217928 PMCID: PMC7698758 DOI: 10.3390/nu12113536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.
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Affiliation(s)
- Anna Rybak
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
- Correspondence:
| | - Aruna Sethuraman
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London E1 2AJ, UK;
| | - Jutta Koeglmeier
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Keith Lindley
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Osvaldo Borrelli
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
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Babaei A, Shad S, Massey BT. Diagnostic differences in the pharmacologic response to cholecystokinin and amyl nitrite in patients with absent contractility vs type I Achalasia. Neurogastroenterol Motil 2020; 32:e13857. [PMID: 32350982 DOI: 10.1111/nmo.13857] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/07/2019] [Revised: 02/22/2020] [Accepted: 03/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Absent esophageal contractility (AC) is distinguished from type 1 achalasia (ACH1) during high-resolution manometry (HRM) on the basis of normal or elevated deglutitive integrated relaxation pressure (IRP) values. However, IRP measurements are subject to pressure recording error. We hypothesized that distinctive responses to pharmacologic provocation using amyl nitrite (AN) and cholecystokinin (CCK) could reliably distinguish AC patients from those with ACH1. AIM To compare esophageal response with AN and CCK in a well-defined cohort of ACH1 and AC patients. METHOD All available clinical, radiographic, endoscopic, and manometric information in 34 patients with aperistalsis was reviewed to determine the final diagnosis of ACH1 and AC. The differences in response to provocative challenges with the rapid drink challenge (RDC) test and administration of AN and CCK were compared between these two groups. RESULTS Eighteen patients were diagnosed with ACH1 and sixteen with AC. While IRP values were significantly higher in ACH1, the standard criterion value misclassified four AC patients as having ACH1 and five ACH1 patients as having AC. IRP values on the RDC did not accurately segregate AC from ACH1, but we were able to identify AN and CCK esophageal motor response criteria that allowed correct classification of ACH1 and AC patients. CONCLUSIONS Nearly a quarter of AC and ACH1 patients may be misdiagnosed based on manometric IRP criteria alone. Differences in the esophageal motor responses to AN and CCK have the potential to facilitate the correct diagnosis in these challenging patients.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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30
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Achufusi TGO, Sharma A, Zamora EA, Manocha D. Small Intestinal Bacterial Overgrowth: Comprehensive Review of Diagnosis, Prevention, and Treatment Methods. Cureus 2020; 12:e8860. [PMID: 32754400 PMCID: PMC7386065 DOI: 10.7759/cureus.8860] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
Small intestinal bacterial overgrowth (SIBO) is a commonly diagnosed gastrointestinal disorder affecting millions of individuals throughout the United States. It refers to a condition in which there is an excess and imbalance of small intestinal bacteria. Despite its prevalence, it remains underdiagnosed due to the invasive nature of diagnostic testing. Symptoms observed in SIBO, including abdominal distension, bloating, diarrhea, and gas formation, are nonspecific and can overlap with other gastrointestinal disorders. Frequently cited predisposing factors include gastric acid suppression, dysmotility, gastric bypass, and opioids. The diagnostic gold standard remains small bowel aspirate and culture. However, due to its invasive nature, it remains an unpopular method among patients and clinicians alike. Glucose and lactulose breath testing have become the go-to diagnostic method in clinical practice due to its noninvasive nature and low cost. Treatment is guided towards the eradication of bacteria in the small bowel and usually consists of a prolonged course of oral antibiotics. Due to recent advances in our understanding of the human microbiome, we are surely poised for a transformation in our approach to diagnosing and treating this condition.
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Affiliation(s)
- Ted George O Achufusi
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Anuj Sharma
- Gastroenterology, State University of New York Upstate Medical University, Syracuse, USA
| | - Ernesto A Zamora
- Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - Divey Manocha
- Gastroenterology, State University of New York Upstate Medical University, Syracuse, USA
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31
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Alomari M, Hitawala A, Chadalavada P, Covut F, Al Momani L, Khazaaleh S, Gosai F, Al Ashi S, Abushahin A, Schneider A. Prevalence and Predictors of Gastrointestinal Dysmotility in Patients with Hypermobile Ehlers-Danlos Syndrome: A Tertiary Care Center Experience. Cureus 2020; 12:e7881. [PMID: 32489735 PMCID: PMC7255528 DOI: 10.7759/cureus.7881] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Ehlers-Danlos syndrome (EDS), specifically the hypermobility type (hEDS), is associated with a variety of gastrointestinal (GI) conditions. This study aims to evaluate the prevalence of and factors associated with gut dysmotility in patients with hEDS. Methods This is a retrospective study of hEDS patients conducted at the Cleveland Clinic's Center for Personalized Genetic Healthcare between January 2007 and December 2017. Demographics, GI motility testing, endoscopic, and imaging data were extracted from the patients' charts. Results A total of 218 patients with hEDS were identified. Among them, 136 (62.3%) patients had at least one GI symptom at the time of EDS diagnosis. Motility testing was performed and reported in 42 (19.2%) patients. Out of them, five (11.9%) had esophageal dysmotility, 18 (42.8%) had gastroparesis, five (11.9%) had small bowel/colon altered transit time, and four (9.5%) had global dysmotility. In univariable analysis, patients with postural orthostatic tachycardia syndrome (POTS) [odds ratio (OR): 8.88, 95% CI: 3.69-24.9, p<0.0001], fibromyalgia (OR: 4.43, 95% CI: 2.04-10.1, p=0.0002), history of irritable bowel syndrome (OR: 5.01, 95% CI: 2.31-11.2, p<0.0001), and gastroesophageal reflux disease (OR: 3.33, 95% CI: 1.55-7.44, p=0.002) were more likely to be diagnosed with GI dysmotility. On multivariable analysis, only POTS (OR: 5.74, 95% CI: 2.25-16.7, p=0.0005) was significantly associated with an increased likelihood of GI dysmotility. Conclusions This study suggests that GI symptoms are relatively common among patients with hEDS. Of the patients tested for dysmotility, 76.2% were found to have some form of dysmotility. POTS was found to be an independent predictive factor for GI dysmotility.
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Affiliation(s)
| | - Asif Hitawala
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Pravallika Chadalavada
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA.,Oncology, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Fahrettin Covut
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Laith Al Momani
- Internal Medicine, East Tennessee State University, Johnson City, USA
| | | | - Falgun Gosai
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Suleiman Al Ashi
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
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32
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Assia Batzir N, Kishor Bhagwat P, Larson A, Coban Akdemir Z, Bagłaj M, Bofferding L, Bosanko KB, Bouassida S, Callewaert B, Cannon A, Enchautegui Colon Y, Garnica AD, Harr MH, Heck S, Hurst ACE, Jhangiani SN, Isidor B, Littlejohn RO, Liu P, Magoulas P, Mar Fan H, Marom R, McLean S, Nezarati MM, Nugent KM, Petersen MB, Rocha ML, Roeder E, Smigiel R, Tully I, Weisfeld-Adams J, Wells KO, Posey JE, Lupski JR, Beaudet AL, Wangler MF. Recurrent arginine substitutions in the ACTG2 gene are the primary driver of disease burden and severity in visceral myopathy. Hum Mutat 2020; 41:641-654. [PMID: 31769566 PMCID: PMC7720429 DOI: 10.1002/humu.23960] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Received: 07/23/2019] [Revised: 10/04/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023]
Abstract
Visceral myopathy with abnormal intestinal and bladder peristalsis includes a clinical spectrum with megacystis-microcolon intestinal hypoperistalsis syndrome and chronic intestinal pseudo-obstruction. The vast majority of cases are caused by dominant variants in ACTG2; however, the overall genetic architecture of visceral myopathy has not been well-characterized. We ascertained 53 families, with visceral myopathy based on megacystis, functional bladder/gastrointestinal obstruction, or microcolon. A combination of targeted ACTG2 sequencing and exome sequencing was used. We report a molecular diagnostic rate of 64% (34/53), of which 97% (33/34) is attributed to ACTG2. Strikingly, missense mutations in five conserved arginine residues involving CpG dinucleotides accounted for 49% (26/53) of disease in the cohort. As a group, the ACTG2-negative cases had a more favorable clinical outcome and more restricted disease. Within the ACTG2-positive group, poor outcomes (characterized by total parenteral nutrition dependence, death, or transplantation) were invariably due to one of the arginine missense alleles. Analysis of specific residues suggests a severity spectrum of p.Arg178>p.Arg257>p.Arg40 along with other less-frequently reported sites p.Arg63 and p.Arg211. These results provide genotype-phenotype correlation for ACTG2-related disease and demonstrate the importance of arginine missense changes in visceral myopathy.
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Affiliation(s)
- Nurit Assia Batzir
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Pranjali Kishor Bhagwat
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas
| | - Austin Larson
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, Colorado
| | - Zeynep Coban Akdemir
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Maciej Bagłaj
- Department of Pediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Leon Bofferding
- Département de Pédiatrie Néonatologie, Kannerklinik, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Katherine B Bosanko
- Section of Genetics and Metabolism, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Skander Bouassida
- Humboldt Clinic, Vivantes Health Network GmbH, Charité Academic Teaching Hospital, Medical University of Berlin, Berlin, Germany
| | - Bert Callewaert
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
- Department of Biomolecular Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ashley Cannon
- Department of Genetics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yazmin Enchautegui Colon
- Inherited Metabolic Diseases Clinic, Section of Clinical Genetics and Metabolism, University of Colorado Denver, Aurora, Colorado
| | - Adolfo D Garnica
- Section of Genetics and Metabolism, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Margaret H Harr
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sandra Heck
- Département de Pédiatrie Néonatologie, Kannerklinik, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Anna C E Hurst
- Department of Genetics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Bertrand Isidor
- CHU de Nantes, Service de Génétique Médicale, Nantes 44093 Cedex 1, Nantes, France
| | - Rebecca O Littlejohn
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | - Pengfei Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Pilar Magoulas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Helen Mar Fan
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Ronit Marom
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Scott McLean
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | - Marjan M Nezarati
- Genetics Program, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kimberly M Nugent
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | | | - Maria L Rocha
- Humboldt Clinic, Vivantes Health Network GmbH, Charité Academic Teaching Hospital, Medical University of Berlin, Berlin, Germany
| | - Elizabeth Roeder
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | - Robert Smigiel
- Department of Pediatrics, Division of Pediatrics and Rare Disorders, Wroclaw Medical University, Wroclaw, Poland
| | - Ian Tully
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - James Weisfeld-Adams
- Inherited Metabolic Diseases Clinic, Section of Clinical Genetics and Metabolism, University of Colorado Denver, Aurora, Colorado
| | - Katerina O Wells
- Department of Surgery, Division of Colorectal Surgery, Baylor University Medical Center, Dallas, Texas
| | - Jennifer E Posey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - James R Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Arthur L Beaudet
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Michael F Wangler
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
- Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Gilbert MA, Schultz-Rogers L, Rajagopalan R, Grochowski CM, Wilkins BJ, Biswas S, Conlin LK, Fiorino KN, Dhamija R, Pack MA, Klee EW, Piccoli DA, Spinner NB. Protein-elongating mutations in MYH11 are implicated in a dominantly inherited smooth muscle dysmotility syndrome with severe esophageal, gastric, and intestinal disease. Hum Mutat 2020; 41:973-982. [PMID: 31944481 DOI: 10.1002/humu.23986] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 09/10/2019] [Revised: 12/17/2019] [Accepted: 01/13/2020] [Indexed: 12/12/2022]
Abstract
Gastrointestinal motility disorders include a spectrum of mild to severe clinical phenotypes that are caused by smooth muscle dysfunction. We investigated the genetic etiology of severe esophageal, gastric, and colonic dysmotility in two unrelated families with autosomal dominant disease presentation. Using exome sequencing, we identified a 2 base pair insertion at the end of the myosin heavy chain 11 (MYH11) gene in all affected members of Family 1 [NM_001040113:c.5819_5820insCA(p.Gln1941Asnfs*91)] and a 1 base pair deletion at the same genetic locus in Proband 2 [NM_001040113:c.5819del(p.Pro1940Hisfs*91)]. Both variants are predicted to result in a similarly elongated protein product. Heterozygous dominant negative MYH11 pathogenic variants have been associated with thoracic aortic aneurysm and dissection while biallelic null alleles have been associated with megacystis microcolon intestinal hypoperistalsis syndrome. This report highlights heterozygous protein-elongating MYH11 variants affecting the SM2 isoforms of MYH11 as a cause for severe gastrointestinal dysmotility, and we hypothesize that the mechanistic pathogenesis of this disease, dominant hypercontractile loss-of-function, is distinct from those implicated in other diseases involving MYH11 dysfunction.
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Affiliation(s)
- Melissa A Gilbert
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Schultz-Rogers
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Ramakrishnan Rajagopalan
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M Grochowski
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin J Wilkins
- Division of Anatomic Pathology, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sawona Biswas
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura K Conlin
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristin N Fiorino
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,The Suzi and Scott Lustgarten Center for GI Motility, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Radhika Dhamija
- Department of Medical Genetics, Mayo Clinic, Phoenix, Arizona
| | - Michael A Pack
- Division of Gastroenterology, Department of Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Cell and Developmental Biology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric W Klee
- Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Health Sciences, Mayo Clinic, Rochester, Minnesota.,Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota
| | - David A Piccoli
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,The Suzi and Scott Lustgarten Center for GI Motility, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy B Spinner
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Sharif H, Devadason D, Abrehart N, Stevenson R, Marciani L. Imaging Measurement of Whole Gut Transit Time in Paediatric and Adult Functional Gastrointestinal Disorders: A Systematic Review and Narrative Synthesis. Diagnostics (Basel) 2019; 9:E221. [PMID: 31847098 PMCID: PMC6963386 DOI: 10.3390/diagnostics9040221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND functional gastrointestinal disorders (FGID) are common conditions in children and adults, often associated with abnormalities of whole gut transit. Currently, transit tests can be performed using several imaging methods, including tracking of radiopaque markers, gamma scintigraphy with the use of radioisotopes, magnetic tracking methods, tracking of movement of wireless motility capsules, and emerging magnetic resonance imaging (MRI) approaches. OBJECTIVES to review recent literature on diagnostic imaging techniques used to investigate whole gut transit in FGIDs. METHODS a systematic review was carried out. The different techniques are described briefly, with particular emphasis on contemporary literature and new developments, particularly in the field of MRI. CONCLUSIONS emerging MRI capsule marker methods are promising new tools to study whole gut transit in FGIDs.
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Affiliation(s)
- Hayfa Sharif
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham NG7 2UH, UK; (H.S.); (N.A.)
- Amiri Hospital, Ministry of Health, Civil Service Commission, Kuwait City 12025, Kuwait
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK
| | - David Devadason
- Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK;
| | - Nichola Abrehart
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham NG7 2UH, UK; (H.S.); (N.A.)
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK
| | - Rebecca Stevenson
- Precision Imaging Beacon, University of Nottingham, Nottingham NG7 2UH, UK;
| | - Luca Marciani
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham NG7 2UH, UK; (H.S.); (N.A.)
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK
- Precision Imaging Beacon, University of Nottingham, Nottingham NG7 2UH, UK;
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Babaei A, Shad S, Szabo A, Massey BT. Pharmacologic interrogation of patients with esophagogastric junction outflow obstruction using amyl nitrite. Neurogastroenterol Motil 2019; 31:e13668. [PMID: 31236998 PMCID: PMC6693956 DOI: 10.1111/nmo.13668] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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] [Received: 04/16/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Chicago Classification of esophageal motility includes a group of patients who show evidence of esophagogastric junction outflow obstruction (EGJOO) as demonstrated by elevated integrated relaxation pressure (IRP) and preserved peristalsis. Our aim is to classify EGJOO patients based on response to amyl nitrite (AN) during high-resolution manometry. METHODS Patients were considered to have true EGJOO if elevated IRP during supine swallow persisted in the upright position and was associated with high intrabolus pressure. The EGJ response to AN was compared between patients with achalasia type 2 (A2) and normal esophageal motility. Based on the relaxation gain (deglutitive IRP-AN IRP) value that best discriminated these two groups (10 mm Hg), patients with true EGJOO were categorized as being in either the AN-responsive (AN-R) or AN-unresponsive (AN-U) subgroups. KEY RESULTS In the group of 49 patients with true EGJOO, the AN response classified 27 patients (IRP = 25 ± 10 mm Hg) with AN-R and 22 patients (IRP = 20 ± 5 mm Hg) with AN-U (P = 0.2). In AN-R, AN produced a relaxation gain and rebound after-contraction response at the EGJ comparable to A2 patients. AN-U patients had an elevated IRP after AN and a relaxation gain similar to normal esophageal motility patients. AN-U patients were obese and had higher prevalence of sleep apnea (P < 0.05). CONCLUSIONS Among patients with true EGJOO, only half have pharmacologic evidence of impaired LES relaxation. Pharmacologic interrogation of the EGJ is thus necessary to identify the subgroup of EGJOO patients who could be expected to benefit from LES ablative therapies.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Abstract
INTRODUCTION Intestinal pseudo-obstruction (IPO) is a rare and life-threatening complication of lupus. PATIENT CONCERNS A patient with long-standing lupus developed recurrent abdominal pain and distension as well as nausea and emesis. DIAGNOSIS Imaging showed dilated small bowel loops with air-fluid levels and bowel wall thickening. She also had bilateral hydronephrosis. INTERVENTIONS She was given high-doses of intravenous steroids and cyclophosphamide. OUTCOMES Her symptoms resolved within a week of starting immunosuppression. She was eventually transitioned to mycophenolate mofetil. She remained in remission and immunosuppression was successfully stopped after 1 year. CONCLUSIONS Intestinal pseudo-obstruction is a rare complication of lupus that is often seen in association with ureterohydronephrosis and interstitial cystitis. This clinical syndrome is thought to be because of smooth muscle dysmotility of the gastrointestinal and genitourinary tracts, although the exact mechanism of dysmotility remains unknown. This condition is often responsive to immunosuppression if recognized and treated promptly.
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Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil 2019; 31:e13601. [PMID: 30993800 PMCID: PMC6559831 DOI: 10.1111/nmo.13601] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [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] [Received: 02/08/2019] [Revised: 03/14/2019] [Accepted: 04/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Opioid receptors are present in the esophagus, and chronic opioid therapy may be associated with esophageal dysfunction. Given the current opioid epidemic in the United States, the potential contribution of opioids to esophageal dysmotility is important from both public health and patient care perspectives. Therefore our aim is to investigate the potential contribution of opioids to dysphagia and the prevalence of major motor disorders in patients undergoing manometric evaluation. METHODS The anonymized electronic medical records of patients linked to their de-identified high-resolution manometry (HRM) studies were reviewed. The patients were grouped based on their opioid exposure history at the time of HRM: opioid-naïve and chronic daily users. The oral morphine milligram equivalent daily dose (MMED) of opioids was computed. KEY RESULTS: 10% of patients referred for esophageal HRM were taking opioid analgesics on a chronic daily basis, and they had a significantly higher prevalence of dysphagia than their opioid-naïve counterparts. The chronic daily opioid users displayed a significantly higher prevalence of achalasia type 3 (ACH3) and esophagogastric junction outflow obstruction (EGJOO) motility phenotypes. The MMED of opioids was a significant predictor of esophageal pressure metrics and motility diagnoses (P < 0.0001). CONCLUSIONS Chronic daily opioid intake is associated with impaired deglutitive LES relaxation and disorganized peristaltic sequence. While a minority of patients on chronic daily opioid therapy present with major esophageal motor disorders, they comprise nearly half of ACH3 and a third of EGJOO motility phenotypes.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T. Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Huizinga JD. Recent advances in intestinal smooth muscle research: from muscle strips and single cells, via ICC networks to whole organ physiology and assessment of human gut motor dysfunction. J Smooth Muscle Res 2019; 55:68-80. [PMID: 31956167 PMCID: PMC6962316 DOI: 10.1540/jsmr.55.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 09/28/2019] [Accepted: 11/01/2019] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal smooth muscle research has evolved from studies on muscle strips to spatiotemporal mapping of whole organ motor and electrical activities. Decades of research on single muscle cells and small sections of isolated musculature from animal models has given us the groundwork for interpretation of human in vivo studies. Human gut motility studies have dramatically improved by high-resolution manometry and high-resolution electrophysiology. The details that emerge from spatiotemporal mapping of high-resolution data are now of such quality that hypotheses can be generated as to the physiology (in healthy subjects) and pathophysiology (in patients) of gastrointestinal (dys) motility. Such interpretation demands understanding of the musculature as a super-network of excitable cells (neurons, smooth muscle cells, other accessory cells) and oscillatory cells (the pacemaker interstitial cells of Cajal), for which mathematical modeling becomes essential. The developing deeper understanding of gastrointestinal motility will bring us soon to a level of precision in diagnosis of dysfunction that is far beyond what is currently available.
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Affiliation(s)
- Jan D. Huizinga
- Department of Medicine-Gastroenterology, McMaster University,
Hamilton, Ontario, Canada
- Farncombe Family Digestive Health Research Institute,
Hamilton, Ontario, Canada
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Zoll B, Jehangir A, Malik Z, Edwards MA, Petrov RV, Parkman HP. Gastric Electric Stimulation for Refractory Gastroparesis. J Clin Outcomes Manag 2019; 26:27-38. [PMID: 31501641 PMCID: PMC6733037] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To outline the use and utility of gastric electric stimulation (GES) as a therapeutic intervention for gastroparesis. METHODS Review of the literature. RESULTS Gastroparesis is characterized by delayed gastric emptying, with symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Some patients with gastroparesis do not respond to medical intervention, and for these patients surgical intervention may be warranted. GES utilizes high-frequency gastric neurostimulation to facilitate gastric emptying and reduce symptoms of gastroparesis. It is indicated for patients with idiopathic and diabetic gastroparesis who have nausea and vomiting as their primary symptoms and who have not responded to medical therapy. GES has also been used in postsurgical and pediatric gastroparesis patients. Optimizing the outcome of this surgical treatment through proper patient selection and meticulous surgical technique is essential as there are inherent risks to the procedure. Nonblinded studies of GES for medically refractory gastroparesis have demonstrated therapeutic symptomatic benefit, whereas randomized controlled trials have not. New interventions such as pyloromyotomy and pyloroplasty are reasonable alternatives or addendums to GES. CONCLUSION GES may be considered among the therapies available for treating patients with refractory symptoms of gastroparesis. More studies, specifically those comparing GES, pyloromyotomy, GES combined with pyloromyotomy, and placebo, are needed to help guide therapy selection for refractory gastroparesis.
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Affiliation(s)
- Bryan Zoll
- Temple University School of Medicine, Philadelphia, PA
| | - Asad Jehangir
- Temple University School of Medicine, Philadelphia, PA
| | - Zubair Malik
- Temple University School of Medicine, Philadelphia, PA
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Abstract
BACKGROUND Postural orthostatic tachycardia syndrome encompasses multiple disabling symptoms that interfere with daily activities. Non-pharmacologic approaches can be insufficient and can require adjunctive medications to manage symptoms. Minimal data exist in the literature on medication outcomes in these patients. We reviewed our database for medication management outcomes.Materials and MethodsPatients aged 18 years and younger at initial diagnosis met the inclusion criteria. All prescribed patient medications were extracted from the electronic health record, excluding medications for unrelated symptoms or comorbid diseases. Medications were grouped by symptom class consistent with our programme utilisation protocol. Within symptom classification, therapy was deemed successful when a specific dose was prescribed at least five consecutive times without changes; this was confirmed by chart review. Individual medications and overall percentage of successful therapies within symptom classifications were assessed, with further analysis by gender. t-Test, χ2, and Mann-Whitney U-test were used to assess for differences in specific variables, as appropriate. RESULTS A total of 708 patients met the study criteria. The percentage of patients with effective therapy by symptom includes light-headedness (52.2%), headache (48.2%), nausea (39.1%), dysmotility (43.4%), pain (53.4%), and insomnia (42.8%). Insomnia therapy was better for females; all other therapies showed no gender difference. The median number of therapies prescribed per patient per symptom was 2 for light-headedness, headache, and insomnia, and 1 for nausea, dysmotility, and pain.DiscussionSymptoms associated with this disorder can be effectively managed with various medications. Further randomised studies are needed to better ascertain true efficacy compared with placebo.
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Matsumoto K, Kawanaka H, Hori M, Kusamori K, Utsumi D, Tsukahara T, Amagase K, Horie S, Yamamoto A, Ozaki H, Mori Y, Kato S. Role of transient receptor potential melastatin 2 in surgical inflammation and dysmotility in a mouse model of postoperative ileus. Am J Physiol Gastrointest Liver Physiol 2018; 315:G104-G116. [PMID: 29565641 DOI: 10.1152/ajpgi.00305.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 02/06/2023]
Abstract
In this study, we investigated the role of transient receptor potential melastatin 2 (TRPM2), a nonselective cation channel abundantly expressed in inflammatory cells such as macrophages, in the development of postoperative ileus, a complication of abdominal surgery characterized by gastrointestinal dysmotility. In wild-type mice, we found that intestinal manipulation, a maneuver that elicits symptoms typical of postoperative ileus, delays the transit of fluorescein-labeled dextran, promotes the infiltration of CD68+ macrophages, Ly6B.2+ neutrophils, and MPO+ cells into intestinal muscles, boosts expression of IL-1β, IL-6, TNF-α, iNOS, and CXCL2 in intestinal muscles and peritoneal macrophages, enhances phosphorylation of ERK and p38 MAPK in intestinal muscles, and amplifies IL-1β, IL-6, TNF-α, iNOS, and CXCL2 expression in resident and thioglycolate-elicited peritoneal macrophages following exposure to lipopolysaccharide. Remarkably, TRPM2 deficiency completely blocks or diminishes these effects. Indeed, intestinal manipulation appears to activate TRPM2 in resident muscularis macrophages and elicits release of inflammatory cytokines and chemokines, which, in turn, promote infiltration of macrophages and neutrophils into the muscle, ultimately resulting in dysmotility. NEW & NOTEWORTHY Activation of transient receptor potential melastatin 2 (TRPM2) releases inflammatory cytokines and chemokines, which, in turn, promote the infiltration of inflammatory cells and macrophages into intestinal muscles, ultimately resulting in dysmotility. Thus TRPM2 is a promising target in treating dysmotility due to postoperative ileus, a complication of abdominal surgery.
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Affiliation(s)
- Kenjiro Matsumoto
- Division of Pathological Sciences, Department of Pharmacology and Experimental Therapeutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Hiroki Kawanaka
- Division of Pathological Sciences, Department of Pharmacology and Experimental Therapeutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Masatoshi Hori
- Department of Veterinary Pharmacology, Graduate School of Agriculture and Life Sciences, The University of Tokyo , Tokyo , Japan
| | - Kosuke Kusamori
- Division of Clinical Pharmaceutical Sciences, Department of Biopharmaceutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Daichi Utsumi
- Division of Pathological Sciences, Department of Pharmacology and Experimental Therapeutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Takuya Tsukahara
- Division of Pathological Sciences, Department of Pharmacology and Experimental Therapeutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Kikuko Amagase
- Division of Pathological Sciences, Department of Pharmacology and Experimental Therapeutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Syunji Horie
- Laboratory of Pharmacology, Faculty of Pharmaceutical Sciences, Josai International University , Chiba , Japan
| | - Akira Yamamoto
- Division of Clinical Pharmaceutical Sciences, Department of Biopharmaceutics, Kyoto Pharmaceutical University , Kyoto , Japan
| | - Hiroshi Ozaki
- Department of Veterinary Pharmacology, Graduate School of Agriculture and Life Sciences, The University of Tokyo , Tokyo , Japan
| | - Yasuo Mori
- Department of Synthetic Chemistry and Biological Chemistry, Graduate School of Engineering, Kyoto University , Kyoto , Japan
| | - Shinichi Kato
- Division of Pathological Sciences, Department of Pharmacology and Experimental Therapeutics, Kyoto Pharmaceutical University , Kyoto , Japan
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Nee J, Rangan V, Lembo A. Reduction in pain: Is it worth the gain? The effect of opioids on the GI tract. Neurogastroenterol Motil 2018; 30:e13367. [PMID: 29700963 DOI: 10.1111/nmo.13367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 03/24/2018] [Accepted: 03/30/2018] [Indexed: 02/08/2023]
Abstract
The use of opioid medications for acute and chronic pain has increased significantly in the past 20 years in the United States. Given the high density of opioid receptors in the gastrointestinal tract, side effects are common in these patients including constipation, dysphagia, bloating, nausea, and vomiting. These side effects, which are experienced by most patients who take opioids, can lead to significant impairment in quality of life. Unlike other side effects from opioids, gastrointestinal side effects do not diminish with continued use, often leading patients to reduce or discontinue their opioid treatment to relieve these side effects. Therefore, physicians must be aware and anticipate potential side effects in patients receiving opioids to ensure appropriate pain management.
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Affiliation(s)
- J Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - V Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - A Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Sanagapalli S, Emmanuel A, Leong R, Kerr S, Lovat L, Haidry R, Banks M, Graham D, Raeburn A, Zarate-Lopez N, Sweis R. Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge. Neurogastroenterol Motil 2018; 30:e13330. [PMID: 29542847 DOI: 10.1111/nmo.13330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 11/29/2017] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE. METHODS Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance. KEY RESULTS Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01). CONCLUSIONS & INFERENCES Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis.
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Affiliation(s)
- S Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK
| | - A Emmanuel
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Leong
- GI Physiology Unit, University College London Hospital, London, UK
| | - S Kerr
- GI Physiology Unit, University College London Hospital, London, UK
| | - L Lovat
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Haidry
- GI Physiology Unit, University College London Hospital, London, UK
| | - M Banks
- GI Physiology Unit, University College London Hospital, London, UK
| | - D Graham
- GI Physiology Unit, University College London Hospital, London, UK
| | - A Raeburn
- GI Physiology Unit, University College London Hospital, London, UK
| | - N Zarate-Lopez
- GI Physiology Unit, University College London Hospital, London, UK
| | - R Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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de Jonge CS, Smout AJPM, Nederveen AJ, Stoker J. Evaluation of gastrointestinal motility with MRI: Advances, challenges and opportunities. Neurogastroenterol Motil 2018; 30. [PMID: 29265641 DOI: 10.1111/nmo.13257] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [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: 10/12/2017] [Accepted: 10/30/2017] [Indexed: 12/19/2022]
Abstract
Dynamic magnetic resonance imaging (MRI) of gastrointestinal motility has developed rapidly over the past few years. The non-invasive and non-ionizing character of MRI is an important advantage together with the fact that it is fast and can visualize the entire gastrointestinal tract. Advances in imaging and quantification techniques have facilitated assessment of gastric, small intestinal, and colonic motility in a clinical setting. Automated quantitative motility assessment using dynamic MRI meets the need for non-invasive techniques. Recently, studies have begun to examine this technique in patients, including those with IBD, pseudo-obstruction and functional bowel disorders. Remaining challenges for clinical implementation are processing the large amount of data, standardization and validation of the numerous MRI metrics and subsequently assessment of the potential role of dynamic MRI. This review examines the methods, advances, and remaining challenges of evaluation of gastrointestinal motility with MRI. It accompanies an article by Khalaf et al. in this journal that describes a new protocol for assessment of pan-intestinal motility in fasted and fed state in a single MRI session.
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Affiliation(s)
- C S de Jonge
- Department of Radiology and Nuclear Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, the Netherlands
| | - A J P M Smout
- Department of Gastroenterology & Hepatology, Academic Medical Center (AMC), Amsterdam, the Netherlands
| | - A J Nederveen
- Department of Radiology and Nuclear Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, the Netherlands
| | - J Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, the Netherlands
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Fikree A, Aziz Q, Sifrim D. Mechanisms underlying reflux symptoms and dysphagia in patients with joint hypermobility syndrome, with and without postural tachycardia syndrome. Neurogastroenterol Motil 2017; 29. [PMID: 28191707 DOI: 10.1111/nmo.13029] [Citation(s) in RCA: 10] [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] [Received: 06/22/2016] [Accepted: 12/19/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The joint hypermobility syndrome (JHS) is a common non-inflammatory connective tissue disorder which frequently co-exists with postural tachycardia syndrome (PoTS), a form of orthostatic intolerance. Gastrointestinal symptoms and dysmotility have been reported in PoTS. Dysphagia and reflux are common symptoms in JHS, yet no studies have examined the physiological mechanism for these, subdivided by PoTS status. METHODS Thirty patients (28 female, ages: 18-62) with JHS and symptoms of reflux (n=28) ± dysphagia (n=25), underwent high-resolution manometry and 24 hour pH-impedance monitoring after questionnaire-based symptom assessment. Esophageal physiology parameters were examined in JHS, subdivided by PoTS status. RESULTS Fifty-three percent of JHS patients with reflux symptoms had pathological acid reflux, 21% had reflux hypersensitivity, and 25% had functional heartburn. Acid exposure was more likely to be increased in the recumbent than upright position (64% vs 43%). The prevalence of hypotensive lower esophageal sphincter (33%) and hiatus hernia (33%) was low. Forty percent of patients with dysphagia had minor disorders of motility, 60% had functional dysphagia. Eighteen (60%) patients had coexistent PoTS-they had significantly higher dysphagia (21 vs 11.5, P=.04) and reflux scores (24.5 vs 16.5, P=.05), and double the prevalence of pathological acid reflux (64% vs 36%, P=.1) and esophageal dysmotility (50% vs 25%, P=.2) though this was not significant. CONCLUSIONS AND INFERENCES A large proportion of JHS patients with esophageal symptoms have true reflux-related symptoms or mild esophageal hypomotility, and this is more likely if they have PoTS.
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Affiliation(s)
- A Fikree
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Q Aziz
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - D Sifrim
- Wingate Institute of Neurogastroenterology, Centre for Digestive Diseases, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Angeli TR, Du P, Paskaranandavadivel N, Sathar S, Hall A, Asirvatham SJ, Farrugia G, Windsor JA, Cheng LK, O'Grady G. High-resolution electrical mapping of porcine gastric slow-wave propagation from the mucosal surface. Neurogastroenterol Motil 2017; 29:10.1111/nmo.13010. [PMID: 28035728 PMCID: PMC5393964 DOI: 10.1111/nmo.13010] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 10/06/2016] [Accepted: 11/19/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastric motility is coordinated by bioelectrical slow waves, and gastric dysrhythmias are reported in motility disorders. High-resolution (HR) mapping has advanced the accurate assessment of gastric dysrhythmias, offering promise as a diagnostic technique. However, HR mapping has been restricted to invasive surgical serosal access. This study investigates the feasibility of HR mapping from the gastric mucosal surface. METHODS Experiments were conducted in vivo in 14 weaner pigs. Reference serosal recordings were performed with flexible-printed-circuit (FPC) arrays (128-192 electrodes). Mucosal recordings were performed by two methods: (i) FPC array aligned directly opposite the serosal array, and (ii) cardiac mapping catheter modified for gastric mucosal recordings. Slow-wave propagation and morphology characteristics were quantified and compared between simultaneous serosal and mucosal recordings. KEY RESULTS Slow-wave activity was consistently recorded from the mucosal surface from both electrode arrays. Mucosally recorded slow-wave propagation was consistent with reference serosal activation pattern, frequency (P≥.3), and velocity (P≥.4). However, mucosally recorded slow-wave morphology exhibited reduced amplitude (65-72% reduced, P<.001) and wider downstroke width (18-31% wider, P≤.02), compared to serosal data. Dysrhythmias were successfully mapped and classified from the mucosal surface, accorded with serosal data, and were consistent with known dysrhythmic mechanisms in the porcine model. CONCLUSIONS & INFERENCES High-resolution gastric electrical mapping was achieved from the mucosal surface, and demonstrated consistent propagation characteristics with serosal data. However, mucosal signal morphology was attenuated, demonstrating necessity for optimized electrode designs and analytical algorithms. This study demonstrates feasibility of endoscopic HR mapping, providing a foundation for advancement of minimally invasive spatiotemporal gastric mapping as a clinical and scientific tool.
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Affiliation(s)
- Timothy R. Angeli
- Auckland Bioengineering Institute, University of Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, University of Auckland, New Zealand
| | | | - Shameer Sathar
- Auckland Bioengineering Institute, University of Auckland, New Zealand
| | - Andrew Hall
- Department of Surgery, University of Auckland, New Zealand
| | | | - Gianrico Farrugia
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Leo K. Cheng
- Auckland Bioengineering Institute, University of Auckland, New Zealand., Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Gregory O'Grady
- Auckland Bioengineering Institute, University of Auckland, New Zealand., Department of Surgery, University of Auckland, New Zealand
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Kumar S, Singh J, Rattan S, DiMarino AJ, Cohen S, Jimenez SA. Review article: pathogenesis and clinical manifestations of gastrointestinal involvement in systemic sclerosis. Aliment Pharmacol Ther 2017; 45:883-898. [PMID: 28185291 PMCID: PMC5576448 DOI: 10.1111/apt.13963] [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: 10/15/2016] [Revised: 11/18/2016] [Accepted: 01/11/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastrointestinal tract (GIT) involvement is a common cause of debilitating symptoms in patients with systemic sclerosis (SSc). There are no disease modifying therapies for this condition and the treatment remains symptomatic, largely owing to the lack of a clear understanding of its pathogenesis. AIMS To investigate novel aspects of the pathogenesis of gastrointestinal involvement in SSc. To summarise existing knowledge regarding the cardinal clinical gastrointestinal manifestations of SSc and its pathogenesis, emphasising recent investigations that may be valuable in identifying potentially novel therapeutic targets. METHODS Electronic (PubMed/Medline) and manual Google search. RESULTS The GIT is the most common internal organ involved in SSc. Any part of the GIT from the mouth to the anus can be affected. There is substantial variability in clinical manifestations and disease course and symptoms are nonspecific and overlapping for a particular anatomical site. Gastrointestinal involvement can occur in the absence of cutaneous disease. Up to 8% of SSc patients develop severe GIT symptoms. This subset of patients display increased mortality with only 15% survival at 9 years. Dysmotiity of the GIT causes the majority of symptoms. Recent investigations have identified a novel mechanism in the pathogenesis of GIT dysmotility mediated by functional anti-muscarinic receptor autoantibodies. CONCLUSIONS Despite extensive investigation, the pathogenesis of gastrointestinal involvement in systemic sclerosis remains elusive. Although treatment currently remains symptomatic, an improved understanding of novel pathogenic mechanisms may allow the development of potentially highly effective approaches including intravenous immunoglobulin and microRNA based therapeutic interventions.
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Affiliation(s)
- Sumit Kumar
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Jagmohan Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Anthony J DiMarino
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Sidney Cohen
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Sergio A. Jimenez
- Jefferson Institute of Molecular Medicine and Scleroderma Center, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
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Rommel N, Rayyan M, Scheerens C, Omari T. The Potential Benefits of Applying Recent Advances in Esophageal Motility Testing in Patients with Esophageal Atresia. Front Pediatr 2017; 5:137. [PMID: 28680874 PMCID: PMC5478877 DOI: 10.3389/fped.2017.00137] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 05/30/2017] [Indexed: 12/12/2022] Open
Abstract
Infants and children with esophageal atresia commonly present with swallowing dysfunction or dysphagia. Dysphagia can lead to a range of significant consequences such as aspiration pneumonia, malnutrition, dehydration, and food impaction. To improve oral intake, the clinical diagnosis of dysphagia in patients with esophageal atresia should focus on both the pharynx and the esophagus. To characterize the complex interactions of bolus flow and motor function between mouth, pharynx, and esophagus, a detailed understanding of normal and abnormal deglutition is required through the use of adequate and objective assessment techniques. As clinical symptoms do not correlate well with conventional assessment methods of motor function such as radiology or manometry but do correlate with bolus flow, the current state-of-the-art diagnosis involves high-resolution manometry combined with impedance measurements to characterize the interplay between esophageal motor function and bolus clearance. Using a novel pressure flow analysis (PFA) method as an integrated analysis method of manometric and impedance measurements, differentiation of patients with impaired esophago-gastric junction relaxation from patients with bolus outflow disorders is clinically relevant. In this, pressure flow matrix categorizing the quantitative PFA measures may be used to make rational therapeutic decisions in patients with esophageal atresia. Through more advanced diagnostics, improved understanding of pathophysiology may improve our patient care by directly targeting the failed biomechanics of both the pharynx and the esophagus.
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Affiliation(s)
- Nathalie Rommel
- Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium.,Experimental Otorhinolaryngology, Department of Neurosciences, Deglutology, University of Leuven, Leuven, Belgium
| | - Maissa Rayyan
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Charlotte Scheerens
- Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium.,Experimental Otorhinolaryngology, Department of Neurosciences, Deglutology, University of Leuven, Leuven, Belgium
| | - Taher Omari
- School of Medicine, Flinders University, Adelaide, SA, Australia
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von Volkmann HL, Nylund K, Tronstad RR, Hovdenak N, Hausken T, Fiskerstrand T, Gilja OH. An activating gucy2c mutation causes impaired contractility and fluid stagnation in the small bowel. Scand J Gastroenterol 2016; 51:1308-15. [PMID: 27338166 DOI: 10.1080/00365521.2016.1200139] [Citation(s) in RCA: 11] [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: 02/04/2023]
Abstract
OBJECTIVE Familial GUCY2C diarrhoea syndrome (FGDS) is caused by an activating mutation in the GUCY2C gene encoding the receptor guanylate cyclase C in enterocytes. Activation leads to increased secretion of fluid into the intestinal lumen. Twenty percent of the patients have increased risk of Crohn's disease and intestinal obstruction (CD, 20%) and the condition resembles irritable bowel syndrome with diarrhoea. We aimed to describe fluid content, contractility, peristaltic activity and bowel wall thickness in the intestine in fasting FGDS patients, using ultrasound, with healthy volunteers serving as controls. METHODS Twenty-three patients with FGDS and 22 healthy controls (HC) were examined with a Logiq E9 scanner in a fasting state. Bowel wall thickness was measured and fluid-filled small bowel loops were counted using three-dimensional (3D) magnetic positioning navigation. The HC ingested 500 ml PEG solution, an electrolyte balanced, non-absorbable solution, in order to investigate the contractions of the small bowel. RESULTS The fasting 23 FGDS patients had significantly higher number of fluid-filled small bowel segments compared to 22 fasting HC, p < 0.001. A high number of non-occlusive contractions in the ileum was observed, which was significant when compared to HC after ingesting PEG solution, p < 0.016. An increase in intestinal wall thickness or other signs of CD were not observed. CONCLUSIONS FGDS is characterised by multiple, fluid-filled small bowel loops with incomplete contractions and fluid stagnation in fasting state. These findings may play a role in the increased risk of bowel obstruction as well as IBS-like symptoms observed in these patients.
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Affiliation(s)
- Hilde Løland von Volkmann
- a National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway ;,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Kim Nylund
- a National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway ;,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Rune Rose Tronstad
- c Department of Pediatrics , Haukeland University Hospital , Bergen , Norway ;,d Department of Clinical Science , University of Bergen , Bergen , Norway
| | - Nils Hovdenak
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Trygve Hausken
- a National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway ;,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | - Torunn Fiskerstrand
- d Department of Clinical Science , University of Bergen , Bergen , Norway ;,e Center for Medical Genetics and Molecular Medicine , Haukeland University Hospital , Bergen , Norway
| | - Odd Helge Gilja
- a National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway ;,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
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Abstract
OBJECTIVE We aimed to review gastric dysmotility in critically ill children: 1) its pathophysiology, with a focus on critical care diseases and therapies that affect gastric motility, 2) diagnostic methodologies, and 3) current and future potential therapies. DATA SOURCES Eligible studies were identified from PubMed and MEDLINE. STUDY SELECTION Literature search included the following key terms: "gastric emptying," "gastric motility/dysmotility," "gastrointestinal motility/dysmotility," "nutrition intolerance," and "gastric residual volume." DATA EXTRACTION Studies since 1995 were extracted and reviewed for inclusion by the authors related to the physiology, pathophysiology, diagnostic methodologies, and available therapies for gastric emptying. DATA SYNTHESIS Delayed gastric emptying, a common presentation of gastric dysmotility, is present in up to 50% of critically ill children. It is associated with the potential for aspiration, ventilator-associated pneumonia, and inadequate delivery of enteral nutrition and may affect the efficacy of enteral medications, all of which may be result in poor patient outcomes. Gastric motility is affected by critical illness and its associated therapies. Currently available diagnostic tools to identify gastric emptying at the bedside have not been systematically studied and applied in this cohort. Gastric residual volume measurement, used as an indirect marker of delayed gastric emptying in PICUs around the world, may be inaccurate. CONCLUSIONS Gastric dysmotility is common in critically ill children and impacts patient safety and outcomes. However, it is poorly understood, inadequately defined, and current therapies are limited and based on scant evidence. Understanding gastric motility and developing accurate bedside measures and novel therapies for gastric emptying are highly desirable and need to be further investigated.
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