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Kim BJ, Kuo B. Gastroparesis and Functional Dyspepsia: A Blurring Distinction of Pathophysiology and Treatment. J Neurogastroenterol Motil 2019; 25:27-35. [PMID: 30509017 PMCID: PMC6326193 DOI: 10.5056/jnm18162] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/26/2018] [Accepted: 10/30/2018] [Indexed: 12/13/2022] Open
Abstract
Gastroparesis and functional dyspepsia are 2 of the most common gastric neuromuscular disorders. These disorders are usually confused, having both similarities and differences. The pathophysiology of these disorders involves abnormal gastric motility, visceral hypersensitivity, mucosal inflammation, and various cellular changes. Both disorders have similar symptoms such as epigastric pain or discomfort, early satiety, and bloating. If patients suspected of having either gastroparesis or functional dyspepsia present with upper gastrointestinal symptoms, they should undergo upper endoscopy to exclude an alternative organic cause. Although the gastric emptying rate is frequently assessed during the clinical workup of patients with gastroparesis or functional dyspepsia, the correlation between gastric emptying and the symptoms is generally poor. Once the diagnosis of gastroparesis or functional dyspepsia is made, treatment should focus on the predominant symptom. Recently, various treatment modalities have been developed and validated. Prokinetic agents are generally used as treatment for both gastroparesis and functional dyspepsia. Acid-suppressive therapy, Helicobacter pylori eradication, and use of drugs that enhance gastric accommodation are employed for functional dyspepsia. Psychoactive drugs are also effective in symptom control. For gastroparesis, antiemetic agents, ghrelin receptor agonists, and serotonergic agents are used aside from prokinetic agents. Acupuncture and gastric electrical stimulation can be attempted. In severe cases, endoscopic and surgical interventions are considered for symptom control.
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Affiliation(s)
- Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea.,Gastrointestinal Unit, Center of Neuroenteric Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Braden Kuo
- Gastrointestinal Unit, Center of Neuroenteric Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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202
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Jacques J, Legros R, Monteil J, Sautereau D, Gourcerol G. Outcomes and Future Directions of Per-Oral Endoscopic Pyloromyotomy: A View from France. Gastrointest Endosc Clin N Am 2019; 29:139-49. [PMID: 30396523 DOI: 10.1016/j.giec.2018.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroparesis is a challenging functional gastroenterological disorder, the complex pathophysiology of which hampers development of therapeutic modalities. Per-oral pyloromyotomy (POP) is a promising endoscopic therapy with a short-term clinical success rate of greater than 80%. Interest in POP is increasing, particularly in France, a country in which there is considerable expertise in submucosal endoscopy and functional disorders. Long-term follow-up and pyloric function evaluation are needed to assess the efficacy of POP in gastroparetic patients.
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203
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Abstract
Although gastroparesis was described more than 60 years ago, the natural history and the long-term outcome are still being clarified. The patients with more severe gastroparesis often seek health care treatment in university medical centers specializing in gastrointestinal motility disorders and hence reports in the literature tend to be based on this population and may not be representative of the entire spectrum. The clinical manifestations of gastroparesis are heterogeneous but a significant proportion of patients end up with substantially poorer quality of life. In this article, the focus is on the clinical presentation and natural history of gastroparesis.
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Affiliation(s)
- Priyadarshini Loganathan
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Richard W McCallum
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX 79905, USA.
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204
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Abstract
Patients with gastroparesis sometimes suffer from intractable nausea and vomiting, abdominal pain, and bloating, as well as a host of other symptoms that can often be difficult to control. Initially, patients are treated conservatively; some do well with conservative management but unfortunately some do not. Over the years, studies have shown the benefits of gastric electrical stimulation, which often results in symptomatic improvement and improvement in gastric emptying times. This article discusses the history of gastric electrical stimulation and its use in clinical practice to help those suffering from gastroparesis that is refractory to conservative medical management.
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Affiliation(s)
- Hadi Atassi
- Department of Medicine, Division of Internal Medicine, University of Louisville, 550 South Jackson Street, ACB A3K00, Louisville, KY 40202, USA
| | - Thomas L Abell
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, 550 South Jackson Street, ACB A3L15, Louisville, KY 40202, USA.
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205
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Abstract
Gastroparesis is a chronic and debilitating neuromuscular disorder of the upper gastrointestinal tract. Symptoms of gastroparesis include nausea, vomiting, epigastric pain, early satiety, and weight loss. Treating gastroparesis can be difficult. Dietary changes may improve symptoms in patients with mild disease. A variety of medications can be used to treat symptoms of nausea and vomiting, although most have not been subjected to randomized controlled trials and only one is approved by the Food and Drug Administration (metoclopramide). Pain management is essential, as nearly 90% of patients report symptoms of epigastric pain. This article reviews treatment options for symptoms of gastroparesis.
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Affiliation(s)
- Christopher M Navas
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Nihal K Patel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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206
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Abstract
OBJECTIVES Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis. MATERIALS AND METHODS Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases. RESULTS Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment. CONCLUSIONS Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.
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Affiliation(s)
- Mattis Bekkelund
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway
| | - Dag A Sangnes
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Jan Gunnar Hatlebakk
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Lars Aabakken
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Transplantation Medicine , Section for Gastroenterology, Oslo University Hospital , Oslo , Norway
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207
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Abstract
Gastroparesis is a syndrome of delayed gastric emptying. First-line treatment includes prokinetic medications. Those refractory to medical treatment are occasionally considered for endoscopic or surgical treatment options, with unpredictable response. The pylorus plays a key role in gastric emptying, with pylorospasm as the underlying mechanism of gastroparesis in some patients. Procedures aiming at disruption of the pylorus have improved gastroparesis symptoms in this subset of patients. These include transpyloric stenting, used for inpatients with refractory symptoms to allow hospital discharge or as a triage to assess symptoms response in patients considered for more definite therapies such as pyloromyotomy.
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208
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Abstract
Gastroparesis is an increasing concern and options remain limited. Diagnosis hinges on recognition of delayed gastric emptying in the absence of mechanical obstruction. Nontransit studies evaluating gastric motility serve a complementary role and may help guide therapy. Treatment consists of a combination of lifestyle and dietary medication, medications (antiemetics, prokinetics, neuromodulators, and accommodation-enhancers), alternative and complementary therapy, endoscopic therapy (pyloric-directed therapy, temporary stimulation, jejunostomy, or venting gastrostomy) and surgical therapy (pyloroplasty, gastric electrical stimulation, gastrectomy). Treatment can be tailored to the individual needs and symptoms of the affected patient.
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Affiliation(s)
- Frances U Onyimba
- Department of Medicine, Division of Gastroenterology, University of California San Diego, 9500 Gillman Drive, #0956, La Jolla, CA 92093, USA
| | - John O Clarke
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, 300 Pasteur Drive, MC 5244, Stanford, CA 94305, USA.
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209
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Gonzalez C, Kwak JM, Davrieux F, Watanabe R, Marescaux J, Swanstrom L. Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome. Surg Endosc 2019; 33:303-8. [PMID: 30334156 DOI: 10.1007/s00464-018-6493-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 10/11/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Gastroparesis is a rapidly increasing problem with sometimes devastating consequences. While surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity, they require general anesthesia, advanced skills, and can lead to leaks. Peroral pyloromyotomy is a less invasive alternative; however, this technique is technically demanding and not widely available. We describe a hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow endoluminal stapled pyloroplasty as an alternative treatment option for gastric outlet obstruction. METHODS Under general anesthesia, six pigs (mean weight 33 kg) underwent endoscopic placement of intragastric ports using a technique similar to percutaneous endoscopic gastrostomy. A 5 mm laparoscope was used for visualization. A functional lumen imagine probe was used to measure the cross-sectional area (CSA) and diameter of the pylorus before, after, and at 1 week after intervention. Pyloroplasty was performed using a 5 mm articulating laparoscopic stapler. Gastrotomies were closed by endoscopic clips, endoscopic suture, or combination. After 6-8 days, a second evaluation was performed. At the end of the protocol, all animals were euthanized. RESULTS Six pyloroplasties were performed. In all cases, this technique was effective in achieving significant pyloric dilatation. The median pre-pyloroplasty pyloric diameter (D) and cross-sectional area (CSA) were 8 mm (4.9-11.6 mm) and 58.6 mm2 (19-107 mm2), respectively. After the procedure, these values increased to 13.41 mm (9.8-17.6 mm) and 147.7 mm2 (76-244 mm2), respectively (p = 0.0152). No important intraoperative events were observed. Postoperatively, all animals did well, with adequate oral intake and no relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent. CONCLUSIONS Hybrid endoluminal stapled pyloroplasty is a feasible, safe, and effective alternative method for the treatment of gastric outlet obstruction syndrome.
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210
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Abstract
Gastroparesis can be divided into diabetic and nondiabetic, and the 3 main causes of gastroparesis are diabetic, postsurgical, and idiopathic. Delayed gastric emptying is the main manifestation of motility disorders for gastroparesis. Symptoms of gastroparesis are nonspecific and severity can vary. Nausea and vomiting are more common in diabetic gastroparesis whereas abdominal pain and early satiety are more frequent in idiopathic gastroparesis. Medication is still the mainstay of treatment of gastroparesis; however, the development of gastric electric stimulation and gastric peroral endoscopic pyloromyotomy brings more options for the treatment of diabetic and nondiabetic gastroparesis.
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Affiliation(s)
- Shanshan Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Jennifer Xu
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA
| | - Vladimir Lamm
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA
| | - Cicily T Vachaparambil
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA
| | - Huimin Chen
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai 200127, China
| | - Qiang Cai
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA.
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211
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Abstract
Gastroparesis is a complex syndrome with symptoms that include nausea, vomiting, and postprandial abdominal pain, and is frequently accompanied by significant delays in gastric emptying. The pathophysiology of diabetic gastroparesis is fairly well understood; however, idiopathic gastroparesis, which accounts for one-third of all cases, may stem from infections, or autoimmune or neurologic disorders, among other causes. To date, few population-based studies have estimated the true prevalence and incidence of gastroparesis. Nonetheless, its prevalence appears to be rising, as does its incidence among minority populations, documented via hospitalizations, which can impose significant economic burdens on patients.
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Affiliation(s)
- Baha Moshiree
- Division of Gastroenterology, University of North Carolina, 1025 Morehead Medical Drive Suite 300, Charlotte, NC 28204, USA; Atrium Health, Carolinas HealthCare System, Digestive Health-Morehead Medical Plaza, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA.
| | - Michael Potter
- Department of Gastroenterology, University of Newcastle, HMRI Building, Kookaburra Circuit, New Lambton Heights, New South Wales 2305, Australia; Department of Gastroenterology, John Hunter Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia
| | - Nicholas J Talley
- Global Research, Digestive and Health Neurogastroenterology, New Lambton, NSW 2305, Australia
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212
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Abstract
Refractory gastroparesis is among the most difficult therapeutic challenges in gastroenterology. Pyloric dysfunction has been described in a subset of patients with gastroparesis, prompting experimentation with botulinum toxin injections into the pylorus, which is relatively safe and has been successfully used in other gastrointestinal disorders. However, causality between pyloric dysfunction and symptoms of gastroparesis has never been demonstrated. Although several open-label studies showed initial promise, 2 randomized clinical trials failed to elicit a difference in clinical outcomes in botulinum toxin versus placebo. Based on current evidence, further use of botulinum toxin for gastroparesis is discouraged outside of a research trial.
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Affiliation(s)
- Trisha S. Pasricha
- Department of Medicine Baltimore, Junior Assistant Resident, Osler Medical Training Program Johns Hopkins Hospital, MD, USA
| | - Pankaj J. Pasricha
- Department of Gastroenterology, Professor of Medicine and Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
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213
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Mekaroonkamol P, Dacha S, Patel V, Li B, Luo H, Shen S, Chen H, Cai Q. Outcomes of Per Oral Endoscopic Pyloromyotomy in the United States. Gastrointest Endosc Clin N Am 2019; 29:151-160. [PMID: 30396525 DOI: 10.1016/j.giec.2018.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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] [Indexed: 02/04/2023]
Abstract
Per oral endoscopic pyloromyotomy (POP) has emerged as an endoscopic intervention for refractory gastroparesis. Early experience in the United States showed exciting clinical response rate, reduced gastroparesis symptoms, improved quality of life, and decreased gastric-emptying time during midterm follow-up up to 18 months. One recent study also showed that the number of patient emergency room visits and hospitalizations decreased significantly after POP. The procedure is technically feasible and safe. As more data become available, it is important to identify patients who would benefit most from this novel procedure.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Sunil Dacha
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Vaishali Patel
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Baiwen Li
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Hui Luo
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Shanshan Shen
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Huimin Chen
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA.
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214
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Spandorfer RM, Zhu Y, Mekaroonkamol P, Galt J, Halkar R, Cai Q. Gastric Emptying Scintigraphy Before Gastric per Oral Endoscopic Myotomy: Imaging May Inform Treatment. Gastrointest Endosc Clin N Am 2019; 29:127-37. [PMID: 30396522 DOI: 10.1016/j.giec.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastric emptying scintigraphy (GES) helps to diagnose gastroparesis and is typically only used for whole stomach retention patterns. However, it may provide significantly more information when looking specifically at proximal and distal retention patterns. This article reviews global GES changes following gastric per oral endoscopic myotomy; how global, proximal, and distal GES measurements correlate to gastroparesis symptoms; and how proximal and distal GES may serve as proxies for the various mechanisms involved in gastroparesis. The authors' data on how GES may be used to select which patients will have success from G-POEM is also reviewed.
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215
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Abstract
Gastroparesis is a debilitating chronic condition of indeterminate cause. Although conservative management is the mainstay of treatment, a significant percentage of patients will need interventions. Interventions range from supportive measures, such as feeding tubes, to more radical surgeries, including endoscopic pyloromyotomy (per oral pyloromyotomy), laparoscopic pyloroplasty, laparoscopic gastric stimulator placement, and even subtotal or total gastrectomy. The authors present some current treatment algorithms focused on the treatment side of the spectrum along with outcomes data to support the various approaches.
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Affiliation(s)
- Ahmed M Zihni
- Division of GI/MIS, The Oregon Clinic, 4805 Northeast Glisan, 6N60, Portland, OR 97213, USA
| | - Christy M Dunst
- Division of GI/MIS, The Oregon Clinic, 4805 Northeast Glisan, 6N60, Portland, OR 97213, USA
| | - Lee L Swanström
- Division of GI/MIS, The Oregon Clinic, 4805 Northeast Glisan, 6N60, Portland, OR 97213, USA; IHU-Strasbourg, 1 Place de l'Hôpital, 67000 Strasbourg, France.
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216
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Revicki DA, Lavoie S, Speck RM, Puelles J, Kuo B, Camilleri M, Almansa C, Parkman HP. The content validity of the ANMS GCSI-DD in patients with idiopathic or diabetic gastroparesis. J Patient Rep Outcomes 2018; 2:61. [PMID: 30547386 PMCID: PMC6292831 DOI: 10.1186/s41687-018-0081-2] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/31/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index-Daily Diary (ANMS GCSI-DD) was developed to meet Food and Drug Administration (FDA) recommendations for patient-reported outcome (PRO) endpoints in gastroparesis studies, including therapeutic trials. The current version of the ANMS GCSI-DD contains five items pertaining to nausea, early satiety, post-prandial fullness, upper abdominal pain, and vomiting. The specific aims of this study were to determine if the appropriate symptoms are included in the ANMS GCSI-DD and to assess the content validity in patients with idiopathic (IG) and diabetic gastroparesis (DG). METHODS Patients diagnosed with IG or DG were recruited by five clinical sites in the United States for a cross-sectional, qualitative study involving one-on-one in-person concept elicitation and cognitive debriefing interviews. Concept elicitation included open-ended questions to elicit patients' symptoms and impacts of gastroparesis, while cognitive debriefing was designed to assess the comprehensiveness of the ANMS GCSI-DD and clarity of the instructions, items, and response scales. The interviews were audio-recorded and transcribed. Transcripts were analyzed using a content analysis approach with ATLAS.ti. RESULTS Of 25 patients interviewed, 15 (60%) had IG and 10 (40%) DG. Mean age of the sample was 42.3 years (range: 20-70 years), and most patients were female (n = 19, 76%) and white (n = 19, 76%). During concept elicitation, patients endorsed the following signs and symptoms as relevant and important to their condition: early satiety (n = 25, 100%), post-prandial fullness (n = 25, 100%), nausea (n = 22, 88%), upper abdominal pain (n = 18, 72%), vomiting (n = 15, 60%), and bloating (n = 11, 44%). Many patients (n = 20, 80%) experienced day-to-day symptom change. During cognitive debriefing, patients confirmed the ANMS GCSI-DD content was comprehensive and reflective of their gastroparesis experience. Patients could easily select a response option and describe how they arrived at their answers. Overall, patients found the instrument's instructions, recall period, items, and response options clear and understandable. CONCLUSIONS The ANMS GCSI-DD was easily understood, found to contain the most important symptoms for patients with IG and DG, and no changes were recommended. Results support the content validity of the ANMS GCSI-DD for clinical trials and clinical care among IG or DG patients.
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Affiliation(s)
| | - Sara Lavoie
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Rebecca M. Speck
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Jorge Puelles
- Takeda Pharmaceuticals, 61 Aldwych, London, WC2B 4AE UK
| | - Braden Kuo
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | | | - Cristina Almansa
- Takeda Pharmaceuticals, 35 Lansdowne Street, Cambridge, MA 02139 USA
| | - Henry P. Parkman
- Temple University Hospital, 3401 N Broad Street, #1003, Philadelphia, PA 19140 USA
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217
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Zikos TA, Clarke JO, Triadafilopoulos G, Regalia KA, Sonu IS, Fernandez-Becker NQ, Nandwani MC, Nguyen LA. A Positive Correlation Between Gastric and Esophageal Dysmotility Suggests Common Causality. Dig Dis Sci 2018; 63:3417-3424. [PMID: 29946871 DOI: 10.1007/s10620-018-5175-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gastric and esophageal dysmotility syndromes are some of the most common motility diagnoses, but little is known about their interrelationship. AIMS The aim of our study was to determine if a correlation exists between gastric and esophageal dysmotility syndromes. METHODS We reviewed the records of all patients who underwent both solid gastric emptying scintigraphy (GES) and high-resolution esophageal manometry (HRM) within a 2 year period, with both done between August 2012 and August 2017. All GESs were classified as either rapid, normal, or delayed. All HRMs were classified according to the Chicago Classification 3.0. Correlations were assessed using Fisher's exact test and multiple logistic regression. RESULTS In total, 482 patients met inclusion criteria. Of patients with a normal, delayed, and rapid GES, 53.1, 64.5, and 77.3% had an abnormal HRM, respectively (p < 0.05 vs. normal GES). Likewise, patients with an abnormal HRM were more likely to have an abnormal GES (54.9 vs. 41.8%, p = 0.005). Multiple logistic regression showed abnormal GES [odds ratio (OR) 2.14], age (OR 1.013), scleroderma (OR 6.29), and dysphagia (OR 2.63) were independent predictors of an abnormal HRM. Likewise, an abnormal HRM (OR 2.11), diabetes (OR 1.85), heart or lung transplantation (OR 2.61), and autonomic dysfunction (OR 2.37) were independent predictors of an abnormal GES. CONCLUSIONS The correlation between an abnormal GES and HRM argues for common pathogenic mechanisms of these motility disorders, and possibly common future treatment options. Clinicians should have a high index of suspicion for another motility disorder if one is present.
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Affiliation(s)
- Thomas A Zikos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA.
| | - John O Clarke
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - George Triadafilopoulos
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Kirsten A Regalia
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Irene S Sonu
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Nielsen Q Fernandez-Becker
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Monica C Nandwani
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
| | - Linda A Nguyen
- Stanford Multidimensional Program for Innovation and Research in the Esophagus (S-MPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA, 94305-5187, USA
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Myint AS, Rieders B, Tashkandi M, Borum ML, Koh JM, Stephen S, Doman DB. Current and Emerging Therapeutic Options for Gastroparesis. Gastroenterol Hepatol (N Y) 2018; 14:639-645. [PMID: 30538604 PMCID: PMC6284339] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Gastroparesis is a complex, debilitating dysmotility disorder with challenging symptom management. A diagnosis of gastroparesis is based on objectively delayed gastric emptying in the absence of mechanical obstruction. Given the limited efficacy of treatment options and serious side effects, significant research continues for therapeutic options for gastroparesis. Promising investigational pharmacologic therapies include relamorelin, prucalopride, and aprepitant. A novel endoscopic therapy is gastric peroral endoscopic pyloromyotomy, which is associated with improved gastric emptying. This article reviews both current and emerging therapeutic options for gastroparesis, including dietary modification and pharmacologic, electrical stimulation, endoscopic, and surgical therapies. Further research and novel treatment options are needed to address the substantial morbidity of gastroparesis.
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Affiliation(s)
- Aung S Myint
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
| | - Brandon Rieders
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
| | - Mohammed Tashkandi
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
| | - Marie L Borum
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
| | - Joyce M Koh
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
| | - Sindu Stephen
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
| | - David B Doman
- Dr Myint, Dr Rieders, and Dr Tashkandi are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC; director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; and is affiliated with Medical Faculty Associates. Dr Koh and Dr Stephen are in private practice in Silver Spring, Maryland. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine and is in private practice in Silver Spring, Maryland
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Yolsuriyanwong K, Marcotte E, Venu M, Chand B. Impact of vagus nerve integrity testing on surgical management in patients with previous operations with potential risk of vagal injury. Surg Endosc 2019; 33:2620-8. [PMID: 30361970 DOI: 10.1007/s00464-018-6562-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Thoracic and foregut operations can cause vagal nerve injury resulting in delayed gastric emptying or gastroparesis. However, the cause of gastroparesis in these patients is not always from a vagal injury. We hypothesize that vagal nerve integrity (VNI) testing may better define who has vagal nerve dysfunction. This information may change subsequent operations. The aim of this study was to evaluate the impact of VNI testing in patients with prior thoracic or gastric surgery. METHODS From January 2014 to December 2017, patients who had previous operations with the potential risk of vagal injury and had VNI testing were reviewed. Excluded patients were those with no plan for a second operation or the second operation was only for gastroparesis. The main outcome was the percentage of operations altered due to the results of VNI testing. RESULTS Twelve patients (eight females) were included. Ages ranged from 37 to 77 years. VNI results were compatible with vagal injury in eight patients (67%). VNI test results altered subsequent operative plans in 41.7% (5/12). Pyloroplasty was done in addition to fundoplication in two patients. Plans for hiatal hernia repair with or without redo-fundoplication in three patients were changed by an additional pyloroplasty in one patient and partial gastrectomy with Roux-en-Y reconstruction in two patients. All patients who had secondary surgery had resolution of symptoms and improvement in objective testing. CONCLUSION The addition of VNI testing in patients with a previous potential risk of vagal nerve injury may help the surgeon select the appropriate secondary operation.
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Ramprasad C, Douglas JY, Moshiree B. Parkinson's Disease and Current Treatments for Its Gastrointestinal Neurogastromotility Effects. ACTA ACUST UNITED AC 2018; 16:489-510. [PMID: 30361854 DOI: 10.1007/s11938-018-0201-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Gastrointestinal disturbances are seen in nearly all patients with Parkinson's disease and lead to impaired quality of life, affect drug pharmacodynamics, and potentially worsen patient's existing motor fluctuations, leading to further disability. Recent evidence links abnormal accumulations of α-synuclein aggregates in the periphery (gut) as seen in the cortex which causes dysfunctions impacting every level of the gastrointestinal tract from the esophagus, to the stomach, small bowel, colon, and rectum and can even predate the onset of the central neurologic disorder itself. Many treatments exist for the clinical phenotypes that result from the autonomic dysfunction and neuropathy involved in this neurodegenerative disorder. The treatments for the gut dysfunction seen in Parkinson's disease (PD) depend on the specific area of the gastrointestinal tract affected. For dysphagia, behavioral therapies with speech pathology, neuromuscular electrical stimulation, or botulinum toxin injection may be helpful. For gastroparesis, domperidone may serve as an antiemetic while also blunting the hypotensive potential of Levodopa while new treatments such as ghrelin agonists may prove beneficial to help appetite, satiety, gastric emptying in those with constipation, and even improve constipation. Antibiotics such as rifaximin with poor systemic absorption may be used to treat small bacterial overgrowth also found in those with PD while the benefits of probiotics is yet to be determined. Finally, constipation in PD can be a reflection of pelvic floor dyssynergia, slow transit constipation, or both, thus treatments targeting the specific anorectal dysfunction is necessary for better outcomes.
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Abstract
PURPOSE OF REVIEW During the past 25 years, there has been an explosion of information regarding the occurrence of gastrointestinal dysfunction in Parkinson's disease. In this review, the clinical features of gastrointestinal dysfunction in Parkinson's disease will be described and information regarding the potential role of the enteric nervous system and the gut microbiome in the genesis of Parkinson's disease will be addressed. RECENT FINDINGS Recognition is growing regarding the role that gastroparesis and small intestinal dysfunction may play in Parkinson's disease, especially with regard to erratic responses to anti-Parkinson medication. The presence of enteric nervous system involvement in Parkinson's disease is now well established, but whether the enteric nervous system is the starting point for Parkinson's disease pathology remains a source of debate. The potential role of the gut microbiome also is beginning to emerge. Gastrointestinal dysfunction is a prominent nonmotor feature of Parkinson's disease and dysfunction can be found along the entire length of the gastrointestinal tract. The enteric nervous system is clearly involved in Parkinson's disease. Whether it is the initial source of pathology is still a source of controversy. There also is growing recognition of the role that the gut microbiome may play in Parkinson's disease, but much more research is needed to fully assess this aspect of the disorder.
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Affiliation(s)
- Ronald F Pfeiffer
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA.
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Burlen J, Runnels M, Mehta M, Andersson S, Ducrotte P, Gourcerol G, Lindberg G, Fullarton G, Abrahamsson H, Al-Juburi A, Lahr C, Rashed H, Abell T. Efficacy of Gastric Electrical Stimulation for Gastroparesis: US/European Comparison. Gastroenterology Res 2018; 11:349-354. [PMID: 30344806 PMCID: PMC6188037 DOI: 10.14740/gr1061w] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/26/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Gastric electrical stimulation (GES) is used in both the US and Europe, but little research has investigated the demographics of gastroparesis patients receiving GES by geographic location. METHODS We compared data from 380 patients, 296 female and 84 males, mean age 42 years, 246 idiopathic (ID), 107 diabetic (DM), and 27 post-surgical (PS). The statistical significance was calculated by Chi-square test and a P-value obtained for ID, DM, and PS. The statistical significance was calculated by Fischer exact test and a P-value obtained comparing male vs. female. RESULTS European centers had 61 GES patients compared to 319 from the US. In Europe, 100% of patients had gastric emptying test (GET) values available; in the US, it was 75% of patients. European centers had more DM patients (59%) than the US (22%), and a smaller proportion of ID patients (25%) than the US (72%). There was a statistical difference between the causes of gastroparesis in the patients receiving GES (P-value < 0.00001). There was also significant difference in the gender of the patients receiving GES, with a greater proportion of women in the US (P value = 0.0023). CONCLUSIONS Comparing GES in US vs. Europe demonstrated significant differences in gastroparesis demographics and percentage of patients with GET data. After analyzing the previously discussed results and reviewing recent updates in evidence-based medicine guidelines, the discrepancy and variance in patient populations in the US and Europe emphasizes the need for a database that allows better analysis and treatment of gastroparesis patients worldwide including stimulation therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Amar Al-Juburi
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Chris Lahr
- Medical University of South Carolina, Charleston, SC, USA
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Corvinus FM, Heinrich S, Neumann H, Hadzijusufovic E, Babic B, Lang H, Grimminger PP. Minimally-invasive temporary gastric stimulation: A pilot study to predict the outcome of electronic gastric stimulation with the Enterra™ system. Dig Liver Dis 2018; 50:1030-1034. [PMID: 29970295 DOI: 10.1016/j.dld.2018.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/04/2018] [Accepted: 05/28/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Gastroparesis (GP) is defined as delayed gastric emptying (GE) without any obstruction of the pylorus. It can be divided into idiopathic, diabetic, post surgical and rare causes. Electronic gastric stimulation (EGS) - Enterra Medtronic™ - is a part of GP therapy. Although its positive impact has been reported in open label trials, randomized controlled trials failed in demonstrating a positive outcome. The aim of this pilot study was to establish a reliable prediction for permanent gastric stimulation. PATIENTS AND PROCEDURE 6 female patients underwent laparoscopic implantation of 2 temporary electrodes. The Enterra™ system was connected and taped to the skin. Baseline and postoperative gastroparesis cardinal symptom index (GCSI), a validated index for GP therapy, was assessed. Response to EGS was defined as a 50% decrease of baseline GCSI. RESULTS 4 of 6 patients responded to temporary EGS. 3 of 4 responders underwent permanent implantation. 1 non-responder received a permanent Enterra™ at another institution. After a median follow up time of 9months the responder group GCSI remained low, whereas the non-responder GCSI had increased. Moreover, the health care system was saved € 30,678.03 by this test stimulation concept. CONCLUSION Laparoscopic implantation of a temporary EGS system predicts the outcome of permanent gastric stimulation and is cost-saving.
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Affiliation(s)
- Florian M Corvinus
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefan Heinrich
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Helmut Neumann
- Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Benjamin Babic
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Peter P Grimminger
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
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Qayed E, Muftah M. Frequency of hospital readmission and care fragmentation in gastroparesis: A nationwide analysis. World J Gastrointest Endosc 2018; 10:200-209. [PMID: 30283603 PMCID: PMC6162246 DOI: 10.4253/wjge.v10.i9.200] [Citation(s) in RCA: 12] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/12/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate rates and predictors of hospital readmission and care fragmentation in patients hospitalized with gastroparesis.
METHODS We identified all adult hospitalizations with a primary diagnosis of gastroparesis in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We excluded patients who died during the hospitalization, and calculated 30 and 90-d unplanned readmission and care fragmentation rates. Readmission to a non-index hospital (i.e., different from the hospital of the index admission) was considered as care fragmentation. A multivariate Cox regression model was used to analyze predictors of 30-d readmissions. Logistic regression was used to determine hospital and patient factors independently associated with 30-d care fragmentation. Patients readmitted within 30 d were followed for 60 d post discharge from the first readmission. Mortality during the first readmission, hospitalization cost, length of stay, and rates of 60-d readmission were compared between those with and without care fragmentation.
RESULTS There were 30064 admissions with a primary diagnosis of gastroparesis. The rates of 30 and 90-d readmissions were 26.8% and 45.6%, respectively. Younger age, male patient, diabetes, parenteral nutrition, ≥ 4 Elixhauser comorbidities, longer hospital stay (> 5 d), large and metropolitan hospital, and Medicaid insurance were associated with increased hazards of 30-d readmissions. Gastric surgery, routine discharge and private insurance were associated with lower 30-d readmissions. The rates of 30 and 90-d care fragmentation were 28.1% and 33.8%, respectively. Younger age, longer hospital stay (> 5 d), self-pay or Medicaid insurance were associated with increased risk of 30-d care fragmentation. Diabetes, enteral tube placement, parenteral nutrition, large metropolitan hospital, and routine discharge were associated with decreased risk of 30-d fragmentation. Patients who were readmitted to a non-index hospital had longer length of stay (6.5 vs 5.8 d, P = 0.03), and higher mean hospitalization cost ($15645 vs $12311, P < 0.0001), compared to those readmitted to the index hospital. There were no differences in mortality (1.0% vs 1.3%, P = 0.84), and 60-d readmission rate (55.3% vs 54.6%, P = 0.99) between the two groups.
CONCLUSION Several factors are associated with the high 30-d readmission and care fragmentation in gastroparesis. Knowledge of these predictors can play a role in implementing effective preventive interventions to high-risk patients.
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Affiliation(s)
- Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30303, United States
- Department of Gastroenterology, Grady Memorial Hospital, Atlanta, GA 30303, United States
| | - Mayssan Muftah
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, United States
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Mussa BM, Sood S, Verberne AJM. Implication of neurohormonal-coupled mechanisms of gastric emptying and pancreatic secretory function in diabetic gastroparesis. World J Gastroenterol 2018; 24:3821-3833. [PMID: 30228777 PMCID: PMC6141338 DOI: 10.3748/wjg.v24.i34.3821] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/22/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
Recently, diabetic gastroparesis (DGP) has received much attention as its prevalence is increasing in a dramatic fashion and management of patients with DGP represents a challenge in the clinical practice due to the limited therapeutic options. DGP highlights an interrelationship between the gastric emptying and pancreatic secretory function that regulate a wide range of digestive and metabolic functions, respectively. It well documented that both gastric emptying and pancreatic secretion are under delicate control by multiple neurohormonal mechanisms including extrinsic parasympathetic pathways and gastrointestinal (GI) hormones. Interestingly, the latter released in response to various determinants that related to the rate and quality of gastric emptying. Others and we have provided strong evidence that the central autonomic nuclei send a dual output (excitatory and inhibitory) to the stomach and the pancreas in response to a variety of hormonal signals from the abdominal viscera. Most of these hormones released upon gastric emptying to provide feedback, and control this process and simultaneously regulate pancreatic secretion and postprandial glycemia. These findings emphasize an important link between gastric emptying and pancreatic secretion and its role in maintaining homeostatic processes within the GI tract. The present review deals with the neurohormonal-coupled mechanisms of gastric emptying and pancreatic secretory function that implicated in DGP and this provides new insights in our understanding of the pathophysiology of DGP. This also enhances the process of identifying potential therapeutic targets to treat DGP and limit the complications of current management practices.
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Affiliation(s)
- Bashair M Mussa
- Department of Basic Medical Science, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Sanjay Sood
- Department of Basic Medical Science, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Anthony JM Verberne
- Department of Medicine, Austin Health, University of Melbourne, Melbourne 3084, Australia
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Jehangir A, Parkman HP. Rome IV Diagnostic Questionnaire Complements Patient Assessment of Gastrointestinal Symptoms for Patients with Gastroparesis Symptoms. Dig Dis Sci 2018; 63:2231-2243. [PMID: 29808246 DOI: 10.1007/s10620-018-5125-1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patient assessment of upper gastrointestinal symptoms (PAGI-SYM) questionnaire assesses severity of gastrointestinal symptoms in gastroparesis (Gp), dyspepsia, and gastroesophageal reflux disease. Rome IV Diagnostic Questionnaire (R4DQ), used to diagnose various functional gastrointestinal disorders, may also help to better understand symptoms of Gp. AIM To assess patients with Gp comparing PAGI-SYM to R4DQ. METHODS Patients with symptoms of Gp referred to our center from May 2016 to January 2018 filled out PAGI-SYM and R4DQ. RESULTS Out of 357 patients, 225 had delayed gastric emptying including 121 with idiopathic gastroparesis (IGp), 60 with diabetic gastroparesis (DGp), 25 with atypical Gp, and 19 with postsurgical gastroparesis (PSGp). Using PAGI-SYM, DGp had more severe retching and vomiting compared to IGp. PSGp had more severe upper abdominal pain compared to IGp. Using R4DQ, the average number of Rome IV diagnoses that Gp patients met criteria was 2.1 ± 0.1. Most Gp patients had functional dyspepsia (n = 197, 90.8%) and chronic nausea and vomiting syndrome (CNVS) (n = 181, 83.4%). Postprandial distress syndrome (PDS) was present in 189 patients (88.3%), and epigastric pain syndrome in 126 patients (59.8%). The combination of PDS and CNVS was seen in 76.5% of Gp patients. CONCLUSIONS In this study, Gp patients were characterized using the PAGI-SYM and R4DQ. DGp had more severe retching and vomiting, while PSGp had more severe upper abdominal pain. PDS and CNVS were the most prevalent Rome IV diagnoses. The combination of PDS and CNVS was typically seen in patients with Gp. R4DQ can be helpful to characterize Gp patients.
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Affiliation(s)
- Asad Jehangir
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
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Malik Z, Kataria R, Modayil R, Ehrlich AC, Schey R, Parkman HP, Stavropoulos SN. Gastric Per Oral Endoscopic Myotomy (G-POEM) for the Treatment of Refractory Gastroparesis: Early Experience. Dig Dis Sci 2018; 63:2405-2412. [PMID: 29468376 DOI: 10.1007/s10620-018-4976-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 02/10/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gastric per oral endoscopic myotomy (G-POEM) of the pylorus is a technique that is recently being used to treat gastroparesis. Our aim was to report our experience in performing G-POEM for refractory gastroparesis of different etiologies and determine symptom improvement. METHODS Thirteen patients undergoing G-POEM are reported. Pre- and post-procedure gastric emptying study (GES) and PAGI-SYM for symptom severity were obtained. Patients underwent G-POEM by creating a submucosal tunnel starting in the greater curvature of the distal antrum and extending it to the beginning of the duodenal bulb, followed by a full thickness pyloromyotomy. RESULTS All 13 gastroparesis patients successfully underwent G-POEM (one diabetic [DGp], four idiopathic [IGp], eight postsurgical [PSGp]). Postsurgical patients included 4 s/p esophagectomy for esophageal cancer, 3 s/p Nissen fundoplication, and 1 s/p esophagectomy for achalasia. There were no procedure-related side effects. Of 11 patients completing follow-up questionnaires, eight were improved subjectively (four patients reported considerably better, four patients somewhat better, one unchanged, and two worse). Individual symptom severity scores tended to improve, particularly vomiting, retching, and loss of appetite. Of six patients that had post-G-POEM GES; GES improved in four, unchanged in one, and worsened in one). CONCLUSIONS G-POEM for treatment of refractory gastroparesis appears to be a feasible and safe technique that can be successfully performed in patients with a variety of etiologies including different types of postsurgical gastroparesis. Our initial experience suggests that the majority of patients report some improvement in symptoms, particularly symptoms of vomiting, retching, and loss of appetite. Further experience is needed to determine the efficacy and safety of G-POEM and predict those who best respond to this treatment.
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Affiliation(s)
- Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Rahul Kataria
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Rani Modayil
- Division of Gastroenterology, Hepatology, and Nutrition, Winthrop University Hospital, Mineola, NY, USA
| | - Adam C Ehrlich
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Ron Schey
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA.
| | - Stavros N Stavropoulos
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Winthrop University Hospital, Mineola, NY, USA
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228
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Sunata Y, Mori H, Hirai Y, Kubosawa Y, Banno S, Kinoshita S, Nakazato Y, Nishizawa T, Kikuchi M, Uraoka T. A Case of Gastroparesis after Cryoballoon Ablation followed by Medication-Induced Recovery within 6 Months. Case Rep Gastroenterol 2018; 12:473-478. [PMID: 30283280 PMCID: PMC6167679 DOI: 10.1159/000492213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 06/13/2018] [Accepted: 07/17/2018] [Indexed: 11/26/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, and cryoballoon ablation was developed as a new treatment modality for symptomatic AF. Gastroparesis is rarely reported as a transient complication of ablation, and its frequency and risk are not clear. We experienced a rare case of gastroparesis after cryoballoon ablation followed by medication-induced recovery within 6 months.
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Affiliation(s)
- Yukie Sunata
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoko Kubosawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Shigeo Banno
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshihiro Nakazato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshihiro Nishizawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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Gibson D, Drabkin A, Krantz MJ, Mascolo M, Rosen E, Sachs K, Welles C, Mehler PS. Critical gaps in the medical knowledge base of eating disorders. Eat Weight Disord 2018; 23:419-430. [PMID: 29681012 DOI: 10.1007/s40519-018-0503-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Eating disorders are unique in that they inherently have much medical comorbidity both as a part of restricting-type eating disorders and those characterized by purging behaviors. Over the last three decades, remarkable progress has been made in the understanding and treatment of the medical complications of eating disorders. Yet, unfortunately, there is much research that is sorely needed to bridge the gap between current medical knowledge and more effective and evidence-based medical treatment knowledge. These gaps exist in many different clinical areas including cardiology, electrolytes, gastrointestinal and bone disease. In this paper, we discuss some of the knowledge gap areas, which if bridged would help develop more effective medical intervention for this population of patients.
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Affiliation(s)
- Dennis Gibson
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Anne Drabkin
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Mori J Krantz
- Division of Cardiology, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | | | - Elissa Rosen
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Katherine Sachs
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Christine Welles
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Philip S Mehler
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.
- Eating Recovery Center, Denver, 7351E Lowry Blvd, Denver, CO, 80230, USA.
- , Denver, USA.
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230
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Landreneau JP, Strong AT, El-Hayek K, Tu C, Villamere J, Ponsky JL, Kroh MD, Rodriguez JH. Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis. Surg Endosc 2018; 33:773-781. [DOI: 10.1007/s00464-018-6342-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/06/2018] [Indexed: 12/11/2022]
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231
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Abstract
This article is a comprehensive review of diabetic gastroparesis, defined as delayed or disordered gastric emptying, including basic principles and current trends in management. This review includes sections on anatomy and physiology, diagnosis and differential diagnosis as well as management and current guidelines for treatment of diabetic gastroparesis. Diabetic gastroparesis (DGp) is a component of autonomic neuropathy resulting from long-standing poorly controlled type 1 and type 2 diabetes. The diagnostic workup of DGp first excludes obstruction and other causes including medications that may mimic delayed/disordered gastric emptying. Targeting nutrition, hydration, symptomatic relief and glycemic control are mainstays of treatment for DGp. Additionally, optimal treatment of DGp includes good glycemic management, often involving customizing insulin delivery using basal-bolus insulin and technology, including sensor-augmented pumps and continuous glucose monitoring systems. Prokinetic medications may be helpful in DGp symptoms, although only limited number of medications is currently available in the USA. Selected medication-refractory patients with DGp may benefit from gastric neuromodulation, and some from surgical interventions including pyloric therapies that can also be done endoscopically. As is true of any of the diabetic complications, prevention of DGp by early and optimal glycemic control is more cost-effective.Funding: Hansa Medcell, India.
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Affiliation(s)
- Sathya Krishnasamy
- Division of Endocrinology, Metabolism, and Diabetes, University of Louisville, Louisville, KY, USA
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, KY, USA.
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Mahjoub F, Salari R, Yousefi M, Mohebbi M, Saki A, Rezayat KA. Effect of Pistacia atlantica kurdica gum on diabetic gastroparesis symptoms: a randomized, triple-blind placebo-controlled clinical trial. Electron Physician 2018; 10:6997-7007. [PMID: 30128090 PMCID: PMC6092141 DOI: 10.19082/6997] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/08/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Gastroparesis is a recognized problem of type 1 and 2 diabetes mellitus that is defined by delayed gastric emptying. Due to insufficient satisfaction of current treatments, the use of complementary and alternative medicine in this field seems essential. According to Persian medicine, Pistacia atlantica gum has proper effect on gastrointestinal disorder specially stomach diseases. OBJECTIVE The aim of this study was to assess the effect of Pistacia atlantica gum on diabetic gastroparesis symptoms. METHODS A triple-blind randomized placebo-controlled trial on subjects with diabetic gastroparesis was conducted at the clinic of Imam Reza Hospital in Mashhad city in Iran, from November 2016 to May 2017. Fifty-four patients (16.7% males and 83.3% females) enrolled in the 8-week study and were randomly divided into two groups of intervention Pistacia atlantica and placebo groups. Both of the groups had received current dietary advice. Severity of gastroparesis symptoms was assessed with a Gastroparesis cardinal symptom index (GCSI) questionnaire. SPSS software version 16 was used to analyze the data and Generalized Estimating Equation (GEE) model, Independent-samples t-test, Paired-samples t-test, Mann-Whitney U test, and Wilcoxon signed-rank test were used to assess variables. RESULTS All gastroparesis symptoms of patients (14.6% diabetes type 1 and 85.4% diabetes type 2) including nausea/vomiting, postprandial fullness/early satiety, and bloating were significantly declined in each group during study (p<0.0001). Pistacia atlantica gum significantly reduced severity of gastroparesis symptoms including Postprandial fullness/early satiety (p=0.04), Bloating (p<0.0001), and GCSI scores (p=0.001) versus placebo. Systolic blood pressure (p=0.006), BMI (p=0.018), and HbA1c (p=0.038) significantly decreased in the Pistacia atlantica group after the intervention. CONCLUSION This study showed that daily consumption of Pistacia atlantica gum for one month improves diabetic gastroparesis symptoms. TRIAL REGISTRATION The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the code of IRCT2016110630739N1. FUNDING This study was supported by funding (grant no.: 950153) from the Mashhad University of Medical Sciences Research Council, Mashhad, Iran.
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Affiliation(s)
- Fatemeh Mahjoub
- M.D., Ph.D. Candidate of Persian Medicine, Department of Persian Medicine, School of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Roshanak Salari
- Ph.D. of Drug Control, Assistant Professor, Department of Pharmaceutical Sciences in Persian Medicine, School of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdi Yousefi
- M.D., Ph.D. of Persian Medicine, Assistant Professor, Department of Persian Medicine, School of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoud Mohebbi
- M.D., Assistant Professor, Endocrine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Azadeh Saki
- Ph.D. of Biostatistics, Assistant Professor, Department of Epidemiology and Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kambiz Akhavan Rezayat
- M.D., Assistant Professor, Department of Internal Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Zhang H, Qing B, Zheng J. Gastroparesis Following Resection of a Fourth-Ventricle Ependymoma in a Child. World Neurosurg 2018; 117:190-194. [PMID: 29933085 DOI: 10.1016/j.wneu.2018.06.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/07/2018] [Revised: 06/09/2018] [Accepted: 06/11/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gastroparesis following resection of a fourth ventricle tumor has never been reported in the literature. We report a unique case of gastroparesis following resection of a fourth-ventricle ependymoma in a child. CASE DESCRIPTION A 14-year-old boy had a 12-day history of headache, nausea, and vomiting. Magnetic resonance imaging revealed a tumor in the fourth ventricle. He underwent a posterior median craniotomy, and total removal was achieved. Histologic analysis revealed an anaplastic ependymoma (World Health Organization grade III). Three days after surgery, the patient complained of upper abdominal pain, nausea, and vomiting. Computed tomography of the abdomen showed dilatation of the stomach. Gastroscopy revealed moderate gastritis without gastric outlet obstruction. Nine days after surgery, a jejunal feeding tube (J-tube) was placed for nutritional support. Once the patient improved his oral intake and demonstrated that he could keep up with his nutritional requirements, the J-tube was discontinued 19 days after surgery. The patient had no neurologic or gastrointestinal complaints at the 2-month follow up. CONCLUSIONS We report, to our knowledge, the first case of gastroparesis following resection of a fourth-ventricle ependymoma in a child. Gastroparesis can recover spontaneously, which we suspect may be due to reversible injury of the dorsal motor nucleus of the vagus.
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Affiliation(s)
- Hong Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bing Qing
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
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234
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Abstract
Systemic amyloidosis is a group of complex disorders characterized by the extracellular deposition of nonbranching fibrils in various tissues, ultimately leading to a variety of clinical presentations including isolated or multiorgan dysfunction. Amyloid involvement of the gastrointestinal tract is common depending on the subtype of this disease; light chain primary amyloidosis (AL) and secondary amyloidosis (AA) affect the gastrointestinal tract in unique ways due to differing pathophysiology. A case is reported of gastroparesis associated with AL amyloidosis diagnosed by esophagogastroduodenoscopy and study of gastric emptying, then subsequently confirmed by Congo red staining performed on endoscopic biopsies.
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Affiliation(s)
- Matthew Hoscheit
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Afrin Kamal
- Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Cline
- Department of Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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235
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Mancilla Asencio C, Gálvez-Arévalo LR, Tobar Almonacid E, Landskron-Ramos G, Madrid-Silva AM. Evaluation of gastric motility through surface electrogastrography in critically ill septic patients. Comparison of metoclopramide and domperidone effects: A pilot randomized clinical trial. Rev Gastroenterol Mex (Engl Ed) 2018; 84:149-157. [PMID: 29903528 DOI: 10.1016/j.rgmx.2018.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/13/2018] [Accepted: 03/22/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION AND AIMS Critically ill patients present with a broad spectrum of gastrointestinal motility disorders that affect the digestive tract. Our aim was to compare the effect of two prokinetic drugs on gastric electrical rhythm in critically ill septic patients, measured through surface electrogastrography (EGG). MATERIAL AND METHODS A prospective triple-blinded randomized study was conducted on 36 patients admitted to the intensive care unit (ICU) with the diagnosis of septic shock. They were randomized to receive metoclopramide or domperidone. We assessed dominant frequency (DF), percentage distribution over time, and dominant power (DP), which represents the strength of contraction, before and after administration of the study drugs. RESULTS Reliable electrogastrograms were achieved in all patients. In relation to the distribution of DF over time, 64% of patients had dysrhythmia, the mean baseline DF was 2.9 cpm, and the mean DP was 56.5μv After drug administration, 58% of the patients had dysrhythmia, the mean DF increased to 5.7 cpm (P<.05), and the DP did not change (57.4μv2). There were no significant differences between drugs. In the metoclopramide group, the baseline DF was 2.1 cpm and the baseline DP was 26.1μv2. The post-drug values increased to 5.4 cpm and 34.1μv2, respectively. In the domperidone group, the baseline DF was 3.7 cpm and the baseline DP was 86.9μv2. After drug administration, the DF increased to 6.1 cpm and the DP decreased to 83.5μv2. CONCLUSIONS Both metoclopramide and domperidone similarly increased the DF of gastric pacemaker activity and improved gastric motility by restoring a normogastric pattern. Gastric dysmotility is frequent in septic patients.
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Affiliation(s)
- C Mancilla Asencio
- Unidad de Cuidados Intensivos, Hospital Clínico Universidad de Chile, Santiago, Chile; Servicio de Medicina Interna, Hospital Clínico Universidad de Chile, Santiago, Chile.
| | - L R Gálvez-Arévalo
- Unidad de Cuidados Intensivos, Hospital Clínico Universidad de Chile, Santiago, Chile; Servicio de Medicina Interna, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - E Tobar Almonacid
- Unidad de Cuidados Intensivos, Hospital Clínico Universidad de Chile, Santiago, Chile; Servicio de Medicina Interna, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - G Landskron-Ramos
- Laboratorio de Enfermedades Funcionales Digestivas y Motilidad, Sección de Gastroenterología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - A M Madrid-Silva
- Laboratorio de Enfermedades Funcionales Digestivas y Motilidad, Sección de Gastroenterología, Hospital Clínico Universidad de Chile, Santiago, Chile
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236
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Cipriani G, Gibbons SJ, Miller KE, Yang DS, Terhaar ML, Eisenman ST, Ördög T, Linden DR, Gajdos GB, Szurszewski JH, Farrugia G. Change in Populations of Macrophages Promotes Development of Delayed Gastric Emptying in Mice. Gastroenterology 2018; 154:2122-2136.e12. [PMID: 29501441 PMCID: PMC5985210 DOI: 10.1053/j.gastro.2018.02.027] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [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: 12/22/2016] [Revised: 02/15/2018] [Accepted: 02/16/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Muscularis propria macrophages lie close to cells that regulate gastrointestinal motor function, including interstitial cells of Cajal (ICC) and myenteric neurons. In animal models of diabetic gastroparesis, development of delayed gastric emptying has been associated with loss of macrophages that express cytoprotective markers and reduced networks of ICC. Mice with long-term diabetes and normal gastric emptying have macrophages that express anti-inflammatory markers and have normal gastric ICC. Mice homozygous for the osteopetrosis spontaneous mutation in the colony-stimulating factor 1 gene (Csf1op/op) do not have macrophages; when they are given streptozotocin to induce diabetes, they do not develop delayed gastric emptying. We investigated whether population of the gastric muscularis propria of diabetic Csf1op/op mice with macrophages is necessary to change gastric emptying, ICC, and myenteric neurons and investigated the macrophage-derived factors that determine whether diabetic mice do or do not develop delayed gastric emptying. METHODS Wild-type and Csf1op/op mice were given streptozotocin to induce diabetes. Some Csf1op/op mice were given daily intraperitoneal injections of CSF1 for 7 weeks; gastric tissues were collected and cellular distributions were analyzed by immunohistochemistry. CD45+, CD11b+, F4/80+ macrophages were dissociated from gastric muscularis propria, isolated by flow cytometry and analyzed by quantitative real-time polymerase chain reaction. Cultured gastric muscularis propria from Csf1op/op mice was exposed to medium that was conditioned by culture with bone marrow-derived macrophages from wild-type mice. RESULTS Gastric muscularis propria from Csf1op/op mice given CSF1 contained macrophages; 11 of 15 diabetic mice given CSF1 developed delayed gastric emptying and had damaged ICC. In non-diabetic Csf1op/op mice, administration of CSF1 reduced numbers of gastric myenteric neurons but did not affect the proportion of nitrergic neurons or ICC. In diabetic Csf1op/op mice given CSF1 that developed delayed gastric emptying, the proportion of nitrergic neurons was the same as in non-diabetic wild-type controls. Medium conditioned by macrophages previously exposed to oxidative injury caused damage to ICC in cultured gastric muscularis propria from Csf1op/op mice; neutralizing antibodies against IL6R or TNF prevented this damage to ICC. CD45+, CD11b+, and F4/80+ macrophages isolated from diabetic wild-type mice with delayed gastric emptying expressed higher levels of messenger RNAs encoding inflammatory markers (IL6 and inducible nitric oxide synthase) and lower levels of messenger RNAs encoding markers of anti-inflammatory cells (heme oxygenase 1, arginase 1, and FIZZ1) than macrophages isolated from diabetic mice with normal gastric emptying. CONCLUSIONS In studies of Csf1op/op and wild-type mice with diabetes, we found delayed gastric emptying to be associated with increased production of inflammatory factors, and reduced production of anti-inflammatory factors, by macrophages, leading to loss of ICC.
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237
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Abstract
Gastroparesis (Gp) is a chronic disease that presents with clinical symptoms of early satiety, bloating, nausea, vomiting, and abdominal pain. Along with these symptoms, an objective finding of delayed gastric emptying, along with a documented absence of gastric outlet obstruction, are required for diagnosis. This article focuses on updates in the pathogenesis and management of Gp. Recent studies on full thickness biopsies of Gp patients have shed light on the complex interactions of the central, autonomic, and enteric nervous systems, which all play key roles in maintaining normal gut motility. The management of Gp has evolved beyond prokinetics and antiemetics with the use of gastric electrical stimulators (GES). In addition, this review aims to introduce the concept of gastroparesis-like syndrome (GLS). GLS helps groups of patients who have the cardinal symptoms of Gp but have a normal or rapid emptying test. Recent tests have shown that patients with Gp and GLS have similar pathophysiology, benefit greatly from GES placement, and likely should be treated in a similar manner.
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Affiliation(s)
- Nanlong Liu
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, KY, USA
| | - Thomas Abell
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, KY, USA
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238
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Kumar M, Chapman A, Javed S, Alam U, Malik RA, Azmi S. The Investigation and Treatment of Diabetic Gastroparesis. Clin Ther. 2018;40:850-861. [PMID: 29748143 DOI: 10.1016/j.clinthera.2018.04.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/05/2018] [Accepted: 04/17/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE This review provides an update on the investigations and treatment options for gastroparesis. METHODS A comprehensive literature search of Medline, PubMed, Embase and OVID was conducted which included all systematic reviews and research articles that focused on the diagnosis, investigations and management diabetic gastroparesis. FINDINGS Dietary modifications and pharmacologic treatment with prokinetics to increase gastric motility form the mainstay of treatment. However, the use of prokinetics is limited by adverse effects and serious adverse effects, leaving metoclopramide as the only drug approved by the US Food and Drug Administration for the treatment of gastroparesis. Newer therapies, including motilin receptor agonists, ghrelin receptor agonists, and neurokinin receptor antagonists, are currently being investigated. Transpyloric stenting, gastric electrical stimulation, and gastric per-oral endoscopic myotomy provide mechanical options for intervention, and surgical interventions in severe intractable gastroparesis include laparoscopic pyloroplasty or gastrectomy. IMPLICATIONS Advances to better understand the pathophysiology and management of diabetic gastroparesis have been limited, especially with discordance between symptoms and severity of delay in gastric emptying. Established treatment options are limited; however, recent pharmacologic and surgical interventions show promise.
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239
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Abstract
Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure classically performed for the treatment of achalasia. The procedure is based on principles of submucosal endoscopy and is composed of a mucosal incision, submucosal tunneling, myotomy, and mucosal closure. Multiple published studies that collectively include more than 6000 patients reported clinical success in more than 80% to 90% of patients. Recent literature also suggested durability of response over a medium-term follow-up. POEM is associated with a low rate of adverse events when performed by experienced operators. Gastroesophageal reflux is not infrequent after POEM but does not seem significantly different from reflux that occurs after Heller myotomy. POEM also seems to be effective in the treatment of spastic esophageal disorders (eg, jackhammer and diffuse esophageal spasm). Last, the role of gastric POEM (G-POEM) in the treatment of gastroparesis has been investigated in recent studies with promising results.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland.
| | - Petros C Benias
- Division of Gastroenterology and Hepatology, Zucker School of Medicine at Northwell, Manhasset, New York
| | - Lee L Swanstrom
- The Oregon Clinic, Portland, Oregon; Institute for Image Guided Surgery, Strasbourg, France
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240
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Kayawake H, Chen-Yoshikawa TF, Motoyama H, Hamaji M, Nakajima D, Aoyama A, Date H. Gastrointestinal complications after lung transplantation in Japanese patients. Surg Today 2018; 48:883-890. [PMID: 29713813 DOI: 10.1007/s00595-018-1666-3] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/13/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Gastrointestinal complications after lung transplantation (LTx) are an important postoperative morbidity associated with malnutrition and the malabsorption of drugs. We reviewed our experience of managing gastrointestinal complications after LTx. METHODS Between June, 2008 and April, 2017, 160 lung transplants were performed at our institution, as living-donor lobar lung transplants in 77 patients, and as deceased-donor lung transplants in 83. We reviewed, retrospectively, the incidence, type and management of gastrointestinal complications. RESULTS Among the 160 LTx recipients, 58 (36.3%) suffered a collective 70 gastrointestinal complications, the most frequent being gastroparesis, followed by gastroesophageal reflux disease. Two complications were managed surgically, by Nissen fundoplication for gastroesophageal reflux disease in one recipient and Hartmann's operation for sigmoid colon perforation in one. The other 68 complications were managed medically. Two patients died of complications: one, of aspiration pneumonia caused by gastroparesis; and one, of panperitonitis caused by a gastric ulcer. There were no significant differences in overall survival or chronic lung allograft dysfunction-free survival between the patients with and those without gastrointestinal complications. CONCLUSIONS Gastrointestinal complications are not uncommon in LTx recipients and may be serious; therefore, early detection and appropriate treatment are imperative. Surgical management is required for some complications, but most can be managed medically.
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Affiliation(s)
- Hidenao Kayawake
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toyofumi F Chen-Yoshikawa
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideki Motoyama
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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Saadi M, Yu D, Malik Z, Parkman HP, Schey R. Pyloric sphincter characteristics using EndoFLIP ® in gastroparesis. Rev Gastroenterol Mex (Engl Ed) 2018; 83:375-384. [PMID: 29709494 DOI: 10.1016/j.rgmx.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/19/2018] [Accepted: 02/02/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND AIMS Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP®) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection. METHODS EndoFLIP® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12. RESULTS Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain. CONCLUSIONS EndoFLIP® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus.
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Affiliation(s)
- M Saadi
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - D Yu
- Temple Clinical Research Institute, Departamento de Ciencias Clínicas, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - Z Malik
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - H P Parkman
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - R Schey
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos.
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Abstract
PURPOSE OF REVIEW Gastroparesis remains a difficult-to-treat disease with limited therapeutic options. Though patients often have a common syndrome of stereotypic symptoms, the underlying pathophysiology is heterogeneous, often leading to variable treatment responses. Due to limitations in medical and surgical therapies, endoscopic options have been increasingly explored. These options can be broadly categorized into pyloric-directed therapy, non-pyloric-directed therapy, and nutritional support. In this review, we will highlight current and emerging endoscopic options, such as gastric per-oral endoscopic myotomy (G-POEM). RECENT FINDINGS Early retrospective studies on G-POEM offer encouraging results up to one year out, with an acceptable safety profile. Other pyloric-directed therapies, such as pyloric dilation and stenting, have also been explored. While emerging endoscopic therapeutic options are encouraging, efficacy will likely depend on a better characterization of underlying pathophysiology and improved patient selection. Future prospective, controlled studies are needed.
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Affiliation(s)
- Andrew Su
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.
| | - Jeffrey L Conklin
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.,Gastrointestinal Motor Function Laboratory, UCLA, Los Angeles, CA, USA
| | - Alireza Sedarat
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA
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243
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Modi R, Rye P, Cawsey S, Birch DW, Sharma AM. Liraglutide Effects on Upper Gastrointestinal Investigations: Implications Prior to Bariatric Surgery. Obes Surg 2018; 28:2113-2116. [PMID: 29667023 DOI: 10.1007/s11695-018-3249-1] [Citation(s) in RCA: 3] [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] [Indexed: 11/28/2022]
Abstract
Liraglutide is a glucagon-like peptide type 1 (GLP-1) analogue that is approved for long-term obesity management in North America. While bariatric surgery remains the gold standard for weight loss, an increasing number of patients are on liraglutide in the setting of ongoing workup for bariatric surgery. The presence of gastrointestinal symptoms prior to bariatric surgery may prompt testing for dysmotility, which affects surgical decision making. Here we report six cases where treatment with liraglutide was associated with reversible reduction in gastric and esophageal motility in screening for bariatric surgery. While liraglutide is known to delay gastric emptying, there are minimal reports of how this medication affects gastrointestinal investigations used in this context. The implications of these abnormal screening investigations on candidacy for bariatric surgery are discussed.
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Affiliation(s)
- Renuca Modi
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada. .,Edmonton Adult Bariatric Specialty Clinic, Royal Alexandra Hospital, Edmonton, CSC 472, 10240 Kingsway Avenue, Edmonton, AB, T5H 3V9, Canada.
| | - Peter Rye
- Richmond Road Diagnostic Treatment Centre, University of Calgary, Room 18126, 1820 Richmond Road SW, Calgary, AB, T2T 5C7, Canada
| | - Sarah Cawsey
- Edmonton Adult Bariatric Specialty Clinic, Royal Alexandra Hospital, Edmonton, CSC 472, 10240 Kingsway Avenue, Edmonton, AB, T5H 3V9, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Daniel W Birch
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Arya M Sharma
- Edmonton Adult Bariatric Specialty Clinic, Royal Alexandra Hospital, Edmonton, CSC 472, 10240 Kingsway Avenue, Edmonton, AB, T5H 3V9, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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244
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Abstract
This article discusses the most interesting presentations at Digestive Disease Week, held in San Diego, in the field of functional and motor gastrointestinal disorders. One of the most important contributions was undoubtedly the presentation of the new Rome IV diagnostic criteria for functional gastrointestinal disorders. We therefore devote some space in this article to explaining these new criteria in the most common functional disorders. In fact, there has already been discussion of data comparing Rome IV and Rome III criteria in the diagnosis of irritable bowel syndrome, confirming that the new criteria are somewhat more restrictive. From the physiopathological point of view, several studies have shown that the aggregation of physiopathological alterations increases symptom severity in distinct functional disorders. From the therapeutic point of view, more data were presented on the efficacy of acotiamide and its mechanisms of action in functional dyspepsia, the safety and efficacy of domperidone in patients with gastroparesis, and the efficacy of linaclotide both in irritable bowel syndrome and constipation. In irritable bowel syndrome, more data have come to light on the favourable results of a low FODMAP diet, with emphasis on its role in modifying the microbiota. Finally, long-term efficacy data were presented on the distinct treatment options in achalasia.
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Affiliation(s)
- Fermín Mearin
- Instituto de Trastornos Funcionales y Motores Digestivos, Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, España.
| | - Enrique Rey
- Servicio de Aparato Digestivo, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Agustín Balboa
- Instituto de Trastornos Funcionales y Motores Digestivos, Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, España
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245
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Koduru P, Irani M, Quigley EMM. Definition, Pathogenesis, and Management of That Cursed Dyspepsia. Clin Gastroenterol Hepatol 2018; 16:467-479. [PMID: 28899670 DOI: 10.1016/j.cgh.2017.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 07/05/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 02/07/2023]
Abstract
Dyspepsia is an umbrella term used to encompass a number of symptoms thought to originate from the upper gastrointestinal tract. These symptoms are relatively nonspecific; not surprisingly, therefore, a myriad of conditions may present with any one or a combination of these symptoms. Therein lays the clinician's first challenge: detecting the minority who may have a potentially life-threatening disorder, such as gastric cancer, from a population whose symptoms are, for the most part, considered functional in origin. The second challenge lies in the definition and management of those individuals with functional dyspepsia (FD); the major focus of this review. The Rome process has addressed the issue of FD definition and a look back at the evolution of Rome criteria for this disorder illustrates the complexities that have so frustrated us. There has been no shortage of hypotheses to explain symptom pathogenesis in FD; initially focused on gastric sensorimotor dysfunction, these have now strayed well into the duodenum and have come to entertain such factors as immune responses and the microbiome. FD has proven to be an equally challenging area for therapeutics; while the staple approaches of acid suppression and eradication of Helicobacter pylori have some limited efficacy in select populations, strategies to ameliorate symptoms in the majority of sufferers based on presumed pathophysiology have largely foundered. Lacking a validated biomarker(s) FD continues to be an elusive target and is likely to remain so until we can better define the various phenotypes that it must surely contain.
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Affiliation(s)
- Pramoda Koduru
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
| | - Malcolm Irani
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas
| | - Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas.
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246
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Woodhouse S, Hebbard G, Knowles SR. Exploring Symptom Severity, Illness Perceptions, Coping Styles, and Well-Being in Gastroparesis Patients Using the Common Sense Model. Dig Dis Sci 2018; 63:958-65. [PMID: 29468373 DOI: 10.1007/s10620-018-4975-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 02/10/2018] [Indexed: 12/13/2022]
Abstract
AIMS This study aimed to examine the relationships between gastroparesis symptom severity, illness perceptions, coping styles, quality of life (QoL), and psychological distress in patients with gastroparesis, guided by the common sense model. METHODS One hundred and seventy-nine adults with gastroparesis (165 females, 14 males; mean age 41.82 years) completed an online questionnaire. The Gastroparesis Cardinal Symptom Index was used to measure gastroparesis symptom severity, QoL was explored using the PAGI-QOL, illness perceptions were measured using the Brief Illness Perception Questionnaire, the Carver Brief COPE scale assessed coping styles, and psychological distress was investigated using the DASS21. RESULTS Structural equation modeling resulted in a final model with excellent fit. Gastroparesis symptom severity directly influenced illness perceptions (β = .52, p < .001) and QoL (β = .30, p < .001). Illness perceptions directly influenced maladaptive coping (β = - .64, p < .001), psychological distress (β = - .32, p < .001), and QoL (β = .30, p = .01). Maladaptive coping directly influenced psychological distress (β = .62, p < .001), which in turn had a direct influence on QoL (β = - .38, p < .001). CONCLUSIONS The final model showed that the influence of gastroparesis symptom severity on psychological distress was fully mediated by illness perceptions, while the influence on QoL was partially mediated by illness perceptions. The study provides guidance for the development of psychological interventions targeted toward improving mediating psychological factors.
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247
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Jielani A, Fatima T, Hussain JA, Rasheed R. Gastric Emptying Scintigraphy In Assessment Of Chronic Vomiting. J Ayub Med Coll Abbottabad 2018; 30:295-297. [PMID: 29938440] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Gastroparesis being multifocal abnormality is characterized by objective feeling of prolong time of gastric retention without any evidence of anatomical blockage. The key symptoms include early satiety, feeling of fullness after meals, nausea, vomiting, bloating, and upper abdominal pain. Radio isotopic Gastric emptying study using radiolabelled test food is integrated clinically for evaluation of functional gastric motility disorders. We present a young female having abdominal pain and vomiting for two months. She was investigated for anatomical causes and no abnormality was uncovered. Gastric Emptying scintigraphy revealed delayed lag phase and half gastric emptying time consistent with the diagnosis of Gastroparesis.
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Affiliation(s)
- Asif Jielani
- Department of Nuclear Medicine, INOR Cancer Hospital Abbottabad, Pakistan
| | - Tatheer Fatima
- Department of Nuclear Medicine, INOR Cancer Hospital Abbottabad, Pakistan
| | | | - Rashid Rasheed
- Department of Nuclear Medicine, INOR Cancer Hospital Abbottabad, Pakistan
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248
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Cheisson G, Jacqueminet S, Cosson E, Ichai C, Leguerrier AM, Nicolescu-Catargi B, Ouattara A, Tauveron I, Valensi P, Benhamou D. Perioperative management of adult diabetic patients. Preoperative period. Anaesth Crit Care Pain Med 2018; 37 Suppl 1:S9-S19. [PMID: 29559406 DOI: 10.1016/j.accpm.2018.02.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 10/30/2017] [Revised: 02/17/2018] [Accepted: 02/26/2018] [Indexed: 12/27/2022]
Abstract
In diabetic patients undergoing surgery, we recommend assessing glycaemic control preoperatively by assessing glycated haemoglobin (HbA1c) levels and recent capillary blood sugar (glucose) levels, and to adjust any treatments accordingly before surgery, paying particular attention to specific complications of diabetes. Gastroparesis creates a risk of stasis and aspiration of gastric content at induction of anaesthesia requiring the use of a rapid sequence induction technique. Cardiac involvement can be divided into several types. Coronary disease is characterised by silent myocardial ischaemia, present in 30-50% of T2D patients. Diabetic cardiomyopathy is a real cause of heart failure. Finally, cardiac autonomic neuropathy (CAN), although rarely symptomatic, should be investigated because it causes an increased risk of cardiovascular events and a risk of sudden death. Several signs are suggestive of CAN, and confirmation calls for close perioperative surveillance. Chronic diabetic kidney disease (diabetic nephropathy) aggravates the risk of perioperative acute renal failure, and we recommend measurement of the glomerular filtration rate preoperatively. The final step of the consultation concerns the management of antidiabetic therapy. Preoperative glucose infusion is not necessary if the patient is not receiving insulin. Non-insulin drugs are not administered on the morning of the intervention except for metformin, which is not administered from the evening before. The insulins are injected at the usual dose the evening before. The insulin pump is maintained until the patient arrives in the surgical unit. It should be remembered that insulin deficiency in a T1D patient leads to ketoacidosis within a few hours.
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Affiliation(s)
- Gaëlle Cheisson
- Service d'anesthésie - réanimation chirurgicale, hôpitaux universitaires Paris-Sud, AP-HP, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - Sophie Jacqueminet
- Institut de cardio-métabolisme et nutrition, hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Département du diabète et des maladies métaboliques, hôpital de la Pitié-Salpêtrière, 75013 Paris, France
| | - Emmanuel Cosson
- Département d'endocrinologie-diabétologie-nutrition, hôpital Jean-Verdier, université Paris 13, Sorbonne Paris Cité, CRNH-IdF, CINFO, AP-HP, 93140 Bondy, France; Sorbonne Paris Cité, UMR U1153 INSERM / U1125 INRA / CNAM / université Paris 13, 93000 Bobigny, France
| | - Carole Ichai
- Service de réanimation Polyvalente, hôpital Pasteur 2, CHU de Nice, 30, voie Romaine, 06001 Nice cedex 1, France; IRCAN (INSERM U1081, CNRS UMR 7284), University Hospital of Nice, 06001 Nice, France
| | - Anne-Marie Leguerrier
- Service de diabétologie-endocrinologie, CHU de Rennes, CHU Hôpital Sud, 16, boulevard de Bulgarie, 35056 Rennes, France
| | - Bogdan Nicolescu-Catargi
- Service d'endocrinologie - maladies métaboliques, hôpital Saint-André, CHU de Bordeaux, 1, rue Jean-Burguet, 33000 Bordeaux, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care II, Magellan Medico-Surgical Center, CHU de Bordeaux, 33000 Bordeaux, France; INSERM, UMR 1034, Biology of Cardiovascular Diseases, université Bordeaux, 33600 Pessac, France
| | - Igor Tauveron
- Service endocrinologie diabétologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France; UFR médecine, université Clermont-Auvergne, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France; UMR CNRS 6293, INSERM U1103, génétique reproduction et développement, université Clermont-Auvergne, 63170 Aubière, France; Endocrinologie-diabétologie, CHU G. Montpied, BP 69, 63003 Clermont-Ferrand, France
| | - Paul Valensi
- Département d'endocrinologie-diabétologie-nutrition, hôpital Jean-Verdier, université Paris 13, Sorbonne Paris Cité, CRNH-IdF, CINFO, AP-HP, 93140 Bondy, France
| | - Dan Benhamou
- Service d'anesthésie - réanimation chirurgicale, hôpitaux universitaires Paris-Sud, AP-HP, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
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249
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Mehr SE, Barbul A, Shibao CA. Gastrointestinal symptoms in postural tachycardia syndrome: a systematic review. Clin Auton Res 2018; 28:411-421. [PMID: 29549458 DOI: 10.1007/s10286-018-0519-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 11/19/2017] [Accepted: 03/05/2018] [Indexed: 01/06/2023]
Abstract
Gastrointestinal symptoms are among the most common complaints in patients with postural tachycardia syndrome (POTS). In some cases, they dominate the clinical presentation and cause substantial disabilities, including significant weight loss and malnutrition, that require the use of invasive treatment to support caloric intake. Multiple cross-sectional studies have reported a high prevalence of gastrointestinal symptoms in POTS patients with connective tissue diseases, such as Ehlers-Danlos, hypermobile type, and in patients with evidence of autonomic neuropathy. Previous studies that evaluated gastric motility in these patients reported a wide range of abnormalities, particularly delayed gastric emptying. The pathophysiology of gastrointestinal symptoms in POTS is likely multifactorial and probably depends on the co-morbid conditions. In patients with POTS and Ehlers-Danlos syndromes, structural and functional abnormalities in the gastrointestinal connective tissue may play a significant role, whereas in neuropathic POTS, the gastrointestinal tract motility and gut hormonal secretion may be directly impaired due to localized autonomic denervation. In patients with normal gastrointestinal motility but persistent gastrointestinal symptoms, gastrointestinal functional disorders should be considered. We performed a systematic review of the literature related to POTS and gastrointestinal symptoms have proposed possible mechanisms and discussed diagnosis and treatment approaches for delayed gastric emptying, the most common gastrointestinal abnormality reported in patients with POTS.
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Affiliation(s)
- Shahram E Mehr
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA
| | - Adrian Barbul
- Department of Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, 506 RRB, 2222 Pierce Ave, Nashville, TN, 37232, USA.
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250
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Li L, Spandorfer R, Qu C, Yang Y, Liang S, Chen H, Xue H, Cai Q. Gastric per-oral endoscopic myotomy for refractory gastroparesis: A detailed description of the procedure, our experience, and review of the literature. Surg Endosc. 2018;32:3421-3431. [PMID: 29435752 DOI: 10.1007/s00464-018-6112-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 02/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Gastric per-oral endoscopic myotomy (G-POEM) was introduced four years ago as an investigational procedure for refractory gastroparesis. The safety and efficacy were currently evaluated. With our recent studies on G-POEM, we share our experience and knowledge through the discussion of a detailed description of the procedure and review of the literature. To our knowledge, this is the first systemic review on this new therapeutic endoscopic procedure. METHODS The indications and contraindications, various aspects of the procedure, and efficacy assessment are discussed based on our experience and current available data. RESULTS Preoperative preparation, detailed description of the procedure, post-procedural care, and results in the literature are presented. The procedure is safe and effective. 70-80% of patients have significant improvement in overall symptoms and quality of life in short-term (6 months) follow-up, as assessed by Gastric Cardinal Symptom Index and Short Form 36. CONCLUSIONS G-POEM is a feasible and effective procedure for refractory gastroparesis based on early and limited data. Well-designed prospective studies are expected to advance and evaluate this new procedure in the future.
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