Increased prevalence of symptoms of gastroesophageal reflux diseases in type 2 diabetics with neuropathy

Environmental - lifestyle related factors

The prevalence of gastro-oesophageal reflux disease (GORD) has been increasing worldwide. This increase is likely associated with the increased prevalence of obesity, the ageing of the population and the decreased prevalence of Helicobacter pylori (Hp) infection. These different environmental factors interact with GORD pathogenesis in a potentially negative way. Oesophago-gastric junction (OGJ) competence, oesophageal clearance mechanisms and reflux causticity are involved in GORD pathophysiology. Obesity alters GORD pathogenesis by disrupting the OGJ and increasing intragastric pressure. Additionally, the number of transient lower oesophageal sphincter relaxations is potentially increased in obese patients. The potential effect of obesity on oesophageal peristalsis and the implication of impaired oesophageal clearance in GORD pathogenesis are still to establish. Ageing also plays an important role in GORD pathogenesis by decreasing lower oesophageal sphincter pressure and impairing oesophageal clearance. However a link between these abnormalities and an increased acid oesophageal exposure has not yet been demonstrated in the elderly. The role of H. pylori and its eradication remain controversial. The type of Hp gastritis may explain the controversial effect. Hp with antral predominant gastritis is responsible for an increased gastric acid secretion and thus promotes GORD. On the opposite spectrum, Hp with diffuse gastritis induces a gastric atrophy and in this particular case, the Hp eradication may restore acid secretion and lead to a more caustic refluxate in patients with predisposing conditions for GORD. The association of GORD and the type of Hp gastritis remains to be confirmed.

Esophageal obstruction due to enteral feed bezoar: A case report and literature review

This paper describes a rare complication of enteral feeding, esophageal obstruction due to feeding formula bezoar, and reviews the published cases. An attempt to re-insert the nasogastric tube in a chronically ventilated 80-year-old female fed via a nasogastric tube with Jevity^® failed. An esophagogastroduodenoscopy revealed an 18 cm-long concretion of the feeding formula, filling most of the esophageal lumen, which was removed endoscopically. Forty-two cases of feeding formula esophageal bezoars have been reported in the literature. The formation of feeding formula bezoars is triggered by acidic gastroesophageal reflux. The acidic pH in the esophagus causes clotting of the casein in the formula. Predisposing factors for bezoar formation are: mechanical ventilation, supine position, neurological diseases, diabetes mellitus, hypothyroidism, obesity and history of partial gastrectomy. Diagnosis and removal of the bezoar is done endoscopically. Feeding in a semi-recumbent position, administration of prokinetic agents and proton pump inhibitors may prevent this complication.

Acid-related upper endoscopy findings in patients with diabetes versus non-diabetic patients

BACKGROUND

The relationship between diabetes, GERD symptoms and acid-related mucosal damage has not been well studied.

AIMS

To better quantify risk of acid-related mucosal damage among patients with and without diabetes.

METHODS

A prospective study using 10 sites from the Clinical Outcomes Research Initiative (CORI) National Endoscopy Database surveyed patients undergoing EGD by telephone within 30 days on medical history, symptoms and demographics. Varices and feeding tube indications were excluded. Acid-related damage was defined as any of these findings recorded in CORI: Barrett's esophagus; esophageal inflammation (unless non-acid-related etiology); healed ulcer, duodenal, gastric or esophageal ulcer; stricture; and mucosal abnormality with erosion or ulcer.

RESULTS

Of 1,569 patients, 16% had diabetes, 95% being type 2. Diabetic patients were significantly more likely to be male, older and have a higher body mass index, and less likely to report frequent heartburn and non-steroidal anti-inflammatory drug use. No significant differences were found in acid reflux and proton pump inhibitor (PPI) use between groups. In unadjusted analyses, diabetic patients had a similar risk for acid-related damage than non-diabetic patients (OR 1.09; 95% CI: 0.83, 1.42) which persisted after adjusting for gender, age, acid reflux, acid indication and PPI use (OR 1.04; 95% CI: 0.79, 1.39).

CONCLUSIONS

No difference in risk of acid-related mucosal damage was found, even after adjustment for potential confounders. Our data do not support the need for a lower threshold to perform endoscopy in diabetic patients.

Treatment of patients with diabetic gastroparesis

Gastroparesis, or chronic delayed gastric emptying without mechanical obstruction, affects about 40% of patients with type 1 diabetes and up to 30% of patients with type 2 diabetes. Diabetic gastroparesis (DGP) typically causes nausea, vomiting, early satiety, bloating, and postprandial fullness. These symptoms can be extremely troubling and result in poor quality of life. The diagnosis of DGP is made by documenting the presence of chronic upper gastrointestinal (GI) symptoms, ruling out mechanical obstruction, and demonstrating delayed gastric emptying. The usual treatment for DGP includes dietary modifications, prokinetic agents, and antiemetic agents. Although the majority of patients have mild-to-moderate disease that can be managed using these measures, a substantial percentage of patients have severe DGP that is characterized by inadequate oral intake, malnutrition, weight loss, and frequent hospitalizations. Optimal management of these patients presents a difficult challenge for the clinician, although emerging treatment options, such as gastric neurostimulation, are encouraging. Patients with DGP often present with gastric comorbidities, including gastroesophageal reflux disease, intestinal dysmotility, and fungal and bacterial infections of the GI tract. This monograph will present an overview of the pathophysiology of DGP, review diagnostic testing with a discussion of emerging technology, and present the latest research in treatment options for DGP. In addition, management strategies for refractory DGP and gastric comorbidities will be described.

Patients dismissed from the hospital with a diagnosis of noncardiac chest pain: cardiac outcomes and health care utilization

OBJECTIVE

To determine the proportion of patients with noncardiac chest pain (NCCP) who see a gastroenterologist, the type and frequency of gastrointestinal (GI) and cardiac tests performed, and the frequency of cardiac death.

PATIENTS AND METHODS

A cohort of Olmsted County, Minnesota, residents presenting to the emergency department (ED) with chest pain between January 1, 1985, and December 31, 1992, was identified through the Rochester Epidemiology Project. We assessed the frequency of ED, cardiology, and gastroenterology visits and corresponding tests after a diagnosis of NCCP (n=320). We also assessed the frequency of cardiac events.

RESULTS

During follow-up, 49% of patients sought care in the ED, 42% had repeated cardiology evaluations, and 15% were seen by a gastroenterologist. Thirty-eight percent underwent esophagogastroduodenoscopy, but very few underwent manometry or a pH probe. Patients with NCCP of unknown origin had 3 times the rate of GI consultations as their counterparts with a GI disorder. Survival free of cardiac death in the subset with NCCP with a GI disorder was 90.2% at 10 years and 84.8% at 20 years, compared with 93.7% at 10 years and 88.1% at 20 years for the subset with NCCP of unknown origin.

CONCLUSION

The frequency of health care utilization in NCCP patients is high, but relatively few GI consultations and even fewer GI tests are performed. Patients dismissed from the hospital with NCCP continue to experience cardiac events, which may highlight a need for more aggressive cardiovascular risk factor management in this population.

Treatment Challenges in the Management of Gastroparesis-Related GERD

The relationship between gastroparesis and GERD is multi-factorial. The delay in gastric emptying associated with gastroparesis can lead to prolonged gastric retention of food that may have a propensity to reflux. Because gastroparesis allows material to remain in the stomach, there is an increase in the gastroesophageal pressure gradient, gastric volume, and the volume of potential refluxate. Additionally, the prolonged exposure of material in the stomach can increase gastric acid secretion. The onset of gastroparesis has been attributed to several causes, including comorbidities (mainly diabetes), surgical complications, and the use of specific medications (including anticholinergics, narcotics, tricyclic antidepressants, and calcium channel blockers). The etiology of some cases of gastroparesis remain unclear, a condition termed idiopathic gastroparesis. Symptoms commonly associated with gastroparesis or GERD, including nausea, vomiting, and regurgitation, may delay drug absorption. This has the potential to greatly impact systemic absorption and concentration of drugs. Several patient populations may benefit from the use of medication formulations that offer an alternative to swallowing a traditional tablet. In addition, prokinetic drugs, such as metoclopramide, are used in the first-line treatment of gastroparesis to improve the contractility of the gut muscles, as well as the movement of contents through the gastrointestinal system and regulate drug metabolism and absorption.