Generalized transit delay on wireless motility capsule testing in patients with clinical suspicion of gastroparesis, small intestinal dysmotility, or slow transit constipation

Comparison of Gas-sensing Capsule With Wireless Motility Capsule in Motility Disorder Patients

Background/Aims

Motility disorders are prevalent, often leading to disrupted regional or whole gut transit times. In this study, we conducted a comparative analysis between the wireless motility capsule and an innovative gas-sensing capsule to evaluate regional and whole gut transit times in individuals with diagnosed motility disorders.

Methods

We prospectively enrolled 48 patients (34 women) diagnosed with functional dyspepsia and/or functional constipation according to Rome IV criteria. Patients ingested the capsules in tandem. We assessed the agreement between transit times recorded by both devices using Spearman correlation and Bland-Altman analysis. Additionally, diagnostic concordance between the capsules were evaluated using confusion matrices.

Results

We observed a significant correlation between the wireless motility capsule and the gas-sensing capsule for gastric emptying time (r = 0.79, P < 0.001) and colonic transit time (r = 0.66, P < 0.001). The gas-sensing capsule exhibited a sensitivity of 0.83, specificity of 0.96, and accuracy of 0.94 when using the standard cutoff for delayed gastric emptying (5 hours). Similarly, when applying the cutoff value for delayed colonic transit (> 59 hours), the gas-sensing capsule demonstrated a sensitivity of 0.79, specificity of 0.84, and accuracy of 0.82. Importantly, the gas-sensing capsule was well-tolerated, and no serious adverse events were reported during the study.

Conclusions

Our findings underscore the gas-sensing capsule's suitability as a dependable tool for assessing regional and whole gut transit times. It represents a promising alternative to the wireless motility capsule for evaluating patients with suspected motility disorders.

An overview of emerging smart capsules using other-than-light technologies for colonic disease detection

Wireless capsule endoscopy (CE) has revolutionized gastrointestinal diagnostics, offering a non-invasive means to visualize and monitor the GI tract. This review traces the evolution of CE technology. Addressing the limitations of traditional white light (WL) CE, the paper explores non-WL technologies, integrating diverse sensing modalities and novel biomarkers to enhance diagnostic capabilities. Concluding with an assessment of Technology Readiness Levels, the paper emphasizes the transformative impact of non-WL colon CE devices on GI diagnostics, promising more precise, patient-centric, and accessible healthcare for GI disorders.

Biocompatible and Long-Term Monitoring Strategies of Wearable, Ingestible and Implantable Biosensors: Reform the Next Generation Healthcare

Sensors enable the detection of physiological indicators and pathological markers to assist in the diagnosis, treatment, and long-term monitoring of diseases, in addition to playing an essential role in the observation and evaluation of physiological activities. The development of modern medical activities cannot be separated from the precise detection, reliable acquisition, and intelligent analysis of human body information. Therefore, sensors have become the core of new-generation health technologies along with the Internet of Things (IoTs) and artificial intelligence (AI). Previous research on the sensing of human information has conferred many superior properties on sensors, of which biocompatibility is one of the most important. Recently, biocompatible biosensors have developed rapidly to provide the possibility for the long-term and in-situ monitoring of physiological information. In this review, we summarize the ideal features and engineering realization strategies of three different types of biocompatible biosensors, including wearable, ingestible, and implantable sensors from the level of sensor designing and application. Additionally, the detection targets of the biosensors are further divided into vital life parameters (e.g., body temperature, heart rate, blood pressure, and respiratory rate), biochemical indicators, as well as physical and physiological parameters based on the clinical needs. In this review, starting from the emerging concept of next-generation diagnostics and healthcare technologies, we discuss how biocompatible sensors revolutionize the state-of-art healthcare system unprecedentedly, as well as the challenges and opportunities faced in the future development of biocompatible health sensors.

State of the Art in Smart Portable, Wearable, Ingestible and Implantable Devices for Health Status Monitoring and Disease Management

Several illnesses that are chronic and acute are becoming more relevant as the world's aging population expands, and the medical sector is transforming rapidly, as a consequence of which the need for "point-of-care" (POC), identification/detection, and real time management of health issues that have been required for a long time are increasing. Biomarkers are biological markers that help to detect status of health or disease. Biosensors' applications are for screening for early detection, chronic disease treatment, health management, and well-being surveillance. Smart devices that allow continual monitoring of vital biomarkers for physiological health monitoring, medical diagnosis, and assessment are becoming increasingly widespread in a variety of applications, ranging from biomedical to healthcare systems of surveillance and monitoring. The term "smart" is used due to the ability of these devices to extract data with intelligence and in real time. Wearable, implantable, ingestible, and portable devices can all be considered smart devices; this is due to their ability of smart interpretation of data, through their smart sensors or biosensors and indicators. Wearable and portable devices have progressed more and more in the shape of various accessories, integrated clothes, and body attachments and inserts. Moreover, implantable and ingestible devices allow for the medical diagnosis and treatment of patients using tiny sensors and biomedical gadgets or devices have become available, thus increasing the quality and efficacy of medical treatments by a significant margin. This article summarizes the state of the art in portable, wearable, ingestible, and implantable devices for health status monitoring and disease management and their possible applications. It also identifies some new technologies that have the potential to contribute to the development of personalized care. Further, these devices are non-invasive in nature, providing information with accuracy and in given time, thus making these devices important for the future use of humanity.

Assessment of whole gut motility in adolescents using the wireless motility capsule test

Functional gastrointestinal (GI) disorders are often associated with intestinal dysmotility representing a diagnostic challenge. A relatively new method is the wireless motility capsule (WMC) test, which continuously measures pH, pressure, temperature and regional transit times as it passes through the GI tract. In adults, the WMC test was approved for use in the diagnosis of gastroparesis and constipation by assessing GI transit and contractility. We performed the WMC test in nine adolescent patients aged 12-17 years with functional GI symptoms from July 2017 until February 2019. Abnormal transit times were detected in four patients. Three patients showed abnormal transit times of the upper GI tract: in two cases, contractility analysis revealed prolonged gastric retention, and in one patient, abnormal colonic transit was detected.Conclusion: The WMC test is a minimally invasive procedure with potential to expand future diagnostic opportunities for paediatric patients with functional GI disorders and suspected motility disturbances. What is Known: • The assessment of GI transit and contractility of the whole gut is possible with the WMC test which is approved for use in the diagnosis of gastroparesis and constipation in adults. What is New: • The WMC test is a non-invasive diagnostic tool with the potential to expand diagnostic opportunities in paediatric patients by assessing regional and whole gut motility. • In paediatric patients with functional GI disorders, the WMC test could help to make an adequate diagnosis and initiate appropriate therapy.

13 C-gastric emptying breath tests: Clinical use in adults and children

¹³ C-gastric emptying breath tests (¹³ C-GEBT) are validated, reliable, and non-invasive tools for measurement of gastric emptying (GE) velocity of solids and liquids without radiation exposure or risk of toxicity. They are recommended and routinely used for clinical purposes in adult as well as pediatric patients and can be readily performed onsite or even at the patient's home. However, the underlying methodology is rather complex and test results can be influenced by dietary factors, physical activity, concurrent diseases, and medication. Moreover, epidemiological factors can influence gastric emptying as well as production and exhalation of ¹³ CO₂ , which is the ultimate metabolic product measured for all ¹³ C-breath tests. Accordingly, in this issue of Neurogastroenterology & Motility, Kovacic et al. report performance of the ¹³ C-Spirulina breath test in a large group of healthy children and show significant effects of gender, pubertal status, and body size on test results. The purpose of this mini-review is to evaluate the clinical use of ¹³ C-GEBT in adults and children, exploring available protocols, analytical methods, and essential prerequisites for test performance, as well as the role of GE measurements in the light of the current discussion on relevance of delayed GE for symptom generation.

Gastroparesis Symptoms Associated with Intestinal Hypomotility: An Explorative Study Using Wireless Motility Capsule

Objective

Gastric emptying measurements are mandatory in gastroparesis diagnostics, but the association between delayed emptying and symptoms is questionable. It is imperative to find biomarkers better correlated to symptom generation. Hence, we examined the association between symptom severity and gastrointestinal motility measured by wireless motility capsule.

Patients and Methods

In this prospective single-centre study, patients with gastroparesis symptoms were simultaneously investigated with gastric emptying scintigraphy and wireless motility capsule, measuring regional transit times and contractility parameters. Symptom severity was assessed with the Patient Assessment of Upper Gastrointestinal Symptom Severity Index (PAGI-SYM), including the Gastroparesis Cardinal Symptom Index (GCSI).

Results

We included 107 patients (70% women). In the whole patient group, nausea correlated with the gastric (r_s = −0.31, p = 0.007), small bowel (r_s = −0.41, p < 0.001) and colonic (r_s = −0.33, p = 0.012) motility indices. In patients with idiopathic etiology, nausea correlated with small bowel motility index (r_s = −0.81, p < 0.001) and mean stomach pressure (r_s = −0.64, p = 0.013). We also found negative correlations between total GCSI score and maximum pressure of the small bowel (r_s = −0.77, p < 0.001) and colon (r_s = −0.74, p = 0.002). In diabetes patients, total PAGI-SYM score correlated with colonic motility index (r_s = −0.34, p = 0.012), and mean pressure of the colon correlated with upper abdominal pain (r_s = −0.37, p = 0.007). We found no association between symptoms, gastric emptying nor any other transit times.

Conclusion

In patients with gastroparesis symptoms, we found that symptom severity was associated with intestinal hypomotility. Based on these results, gastroparesis diagnostics should also include an evaluation of the small bowel and colon.

Exploring associations between constipation, severity of neurofibromatosis type 1 and NF1 mutational spectrum

Neurofibromatosis type 1 (NF1) is inherited in an autosomal dominant manner and is a rather common rare disease. Until recently, studies on gastrointestinal symptoms in patients with NF1 have been few and mostly described as case reports. In three previously published studies, the frequency of constipation in patients with NF1 has been found to be as high as 30%. In this study, associations between the frequency of constipation and NF1 disease severity and NF1 mutational spectrum were investigated. Among 277 patients with NF1, 49 had constipation. The highest rate of constipation was found among patients with a high perception of NF1 illness burden, and patients with constipation had a significantly higher NF1 illness burden when comparing the “not bothered” and the “very bothered” (p = 0.013). We found no significant association between constipation and the remaining measures on severity of NF1, nor between constipation and genetic variants. When observing the NF1 mutational spectrum, one variant (c.1013A>G (p.Asp338Gly/p.?) was identified in three patients with constipation of which two patients were related. The variant c.2970_2972delAAT (p.Met992del) associated with a mild NF1 phenotype was identified in two related patients with constipation. This study is the first to explore the association between symptoms of constipation, NF1 severity, and NF1 mutational spectrum. The results suggest an association between constipation and a high degree of illness burden. Awareness of this association among physicians could lead to more patients with NF1 being diagnosed with constipation. Constipation impacts on quality of life, hence a timely diagnosis and treatment will improve quality of life.

Diagnostic and clinical utility of the wireless motility capsule in children: A study in patients with functional gastrointestinal disorders

BACKGROUND

The wireless motility capsule (WMC) evaluates gastrointestinal motility and transit simultaneously. We evaluated the utility of the WMC in children with functional gastrointestinal symptoms.

METHODS

Study in children comparing WMC transit and motility parameters between those with upper (UGI) or lower (LGI) gastrointestinal symptoms, nuclear medicine gastric emptying time (NMGET) and/or a colonic radiopaque marker (CROM) study.

KEY RESULTS

We prospectively recruited 57 children (median age 16.45y, range 8.78-17.8y, 44 Female) and 50 completed the study (24 UGI/26 LGI). We found no association between WMC study interpretation, motility and transit parameters and symptoms. WMC and NMGET interpretation agreement observed in 24/34 (70%) (κ = 0.351, p = 0.026) and with CROM in 17/21 (81%) patients (κ = 0.576, p = 0.007). WMC detected abnormal gastric transit in 41% vs. 24% with NMGET (p = 0.04) and abnormal colon transit in 62% vs. 71% of patients by CROM (p = 0.01). We found significant correlation (r = 0.574, p = 0.01) and no difference in median colon transit (p = 0.421) by WMC and CROM. A single WMC motility parameter, mean peak amplitude, was associated with NMGET (p = 0.04), none with CROM. Capsule retention >5 days (n = 9, all passed <2 weeks) was associated with prolonged colon transit, not with symptoms, age and gender.

CONCLUSIONS

WMC is well tolerated in children as young as 8 years old. We found no association between WMC and symptoms, fair agreement with NMGET and strong agreement with CROM. WMC increases the yield of finding gastrointestinal transit abnormalities. Capsule retention in children is associated to prolonged colon transit. Larger studies are needed to further validate these findings.

Impact of gastrointestinal tract variability on oral drug absorption and pharmacokinetics: An UNGAP review

The absorption of oral drugs is frequently plagued by significant variability with potentially serious therapeutic consequences. The source of variability can be traced back to interindividual variability in physiology, differences in special populations (age- and disease-dependent), drug and formulation properties, or food-drug interactions. Clinical evidence for the impact of some of these factors on drug pharmacokinetic variability is mounting: e.g. gastric pH and emptying time, small intestinal fluid properties, differences in pediatrics and the elderly, and surgical changes in gastrointestinal anatomy. However, the link of colonic factors variability (transit time, fluid composition, microbiome), sex differences (male vs. female) and gut-related diseases (chronic constipation, anorexia and cachexia) to drug absorption variability has not been firmly established yet. At the same time, a way to decrease oral drug pharmacokinetic variability is provided by the pharmaceutical industry: clinical evidence suggests that formulation approaches employed during drug development can decrease the variability in oral exposure. This review outlines the main drivers of oral drug exposure variability and potential approaches to overcome them, while highlighting existing knowledge gaps and guiding future studies in this area.

Could Chronic Idiopatic Intestinal Pseudo-Obstruction Be Related to Viral Infections?

Chronic idiopathic intestinal pseudo-obstruction (CIIPO) is a disease characterized by symptoms and signs of small bowel obstruction in the absence of displayable mechanical obstruction. Due to the known neuropathic capacity of several viruses, and their localization in the intestine, it has been hypothesized that such viruses could be involved in the pathogenesis of CIIPO. The most frequently involved viruses are John Cunningham virus, Herpesviridae, Flaviviruses, Epstein–Barr virus and Citomegalovirus. Therefore, the present narrative review aims to sum up some new perspectives in the etiology and pathophysiology of CIIPO.

Pretest and Post-test Probabilities of Diagnoses of Rectal Evacuation Disorders Based on Symptoms, Rectal Exam, and Basic Tests: a Systematic Review

BACKGROUND & AIMS

There is controversy over the utility of symptoms, examination, and tests for diagnosis of rectal evacuation disorders (REDs) or slow-transit constipation (STC). We aimed to ascertain the pooled prevalence, sensitivity, specificity, and likelihood ratios for clinical parameters to determine pretest and post-test probabilities of diagnoses of RED and STC without RED.

METHODS

We searched the MEDLINE and PUBMED databases since 1999 for studies that used binary data to calculate sensitivity, specificity, and likelihood ratios to determine the diagnostic utility of history, symptoms, and tests for RED and STC. RED and STC were defined based on confirmation by at least 1 objective anorectal test or colonic transit test. Controls had normal test results based on the specific protocol in each study.

RESULTS

We reviewed 100 articles; 63 studies of RED and 61 studies of STC met the inclusion criteria. Among 3364 patients with chronic constipation, objective tests demonstrated RED alone, 27.2%; normal transit constipation alone, 37.2%; STC alone, 19.0%; and RED with STC, 16.6%. To diagnose RED, discriminant features were urinary symptoms (specificity, 100%; likelihood ratio, above 10; 58 patients), less than 2 findings of dyssynergia in a digital rectal exam (sensitivity, 83.2%; negative likelihood ratio, 0.2; 462 patients) and rectoanal pressure gradient below -40 mm Hg with high anal pressure during straining (specificity, 100%; likelihood ratio, above 10; 101 patients). The features most strongly associated with STC alone were call to stool (specificity, 91.5%; likelihood ratio, 10.5; 75 patients) and absence of abdominal distension, fullness, or bloating (sensitivity, 92.9%; negative likelihood ratio, 0.1; 93 patients).

CONCLUSIONS

In a systematic review, we found specific symptoms, lack of dyssynergia in a digital rectal exam, and findings on anorectal manometry to be highly informative and critical in evaluation of RED and STC.

Development of innovative tools for investigation of nutrient-gut interaction

The gastrointestinal tract is the key interface between the ingesta and the human body. There is wide recognition that the gastrointestinal response to nutrients or bioactive compounds, particularly the secretion of numerous hormones, is critical to the regulation of appetite, body weight and blood glucose. This concept has led to an increasing focus on “gut-based” strategies for the management of metabolic disorders, including type 2 diabetes and obesity. Understanding the underlying mechanisms and downstream effects of nutrient-gut interactions is fundamental to effective translation of this knowledge to clinical practice. To this end, an array of research tools and platforms have been developed to better understand the mechanisms of gut hormone secretion from enteroendocrine cells. This review discusses the evolution of in vitro and in vivo models and the integration of innovative techniques that will ultimately enable the development of novel therapies for metabolic diseases.

Experience with Esophagogastrointestinal Transit Scintigraphy in the Initial 229 Patients: Multiple Regions of Dysmotility Are Common

The purpose of this investigation was to review our experience with our comprehensive esophagogastrointestinal transit study in the first 229 patients. This scintigraphic study analyzes the motility of the entire gut, from the esophagus through the rectosigmoid colon. Methods: Data were reviewed for our first 2 y of experience with this examination (184 women and 45 men aged 20-79 y [mean ± SD, 44 ± 16 y]). Patients were referred with symptoms suggestive of a motility disorder. They first swallowed ¹¹¹In-diethylenetriaminepentaacetic acid in water for the esophageal-swallow study and then 300 mL for a 30-min ¹¹¹In water-only study, followed by 120 mL of ¹¹¹In water simultaneously with the solid standardized ^99mTc egg-substitute meal. Images and quantification were obtained for esophageal transit, water-only gastric emptying, water-with-solid gastric emptying, small-bowel transit, and colonic transit. Results: Of the 229 patient studies, 45 (20%) were normal. The remaining 184 (80%) had at least 1 region of dysmotility, for a total of 336 regions of abnormal motility. A single region of dysmotility was seen in 92 patients (50%), 2 regions in 50 (27%), 3 regions in 26 (14%), 4 regions in 12 (7%), and 5 regions in 4 (2%). There was a poor correlation between the results of the water-only study and water with the solid meal. Three different patterns of delayed colonic transit were seen. Patient symptoms were often not predictive of the scintigraphic findings. Conclusion: This study highlights the frequent occurrence of dysmotility in more than 1 region of the gastrointestinal tract in patients with a suspected motility disorder and the frequent concurrence of both upper- and lower-tract dysmotility in the same patients. It provides information to referring physicians regarding which motility disorders may be causing the patient symptoms, why the patient is or is not responding to the present therapy, and if and what additional workup and therapy may be needed.

Constipation screening in people taking clozapine: A diagnostic accuracy study

OBJECTIVE

Clozapine is the favoured antipsychotic for treatment-refractory schizophrenia but its safe use requires careful adverse-effect management. Clozapine-induced gastrointestinal hypomotility (CIGH or 'slow-gut') is one of the most common and serious of clozapine's adverse effects. CIGH can lead to paralytic ileus, bowel obstruction, gastrointestinal ischaemia, toxic megacolon, and death. Enquiring about constipation is a simple and commonly used screening method for CIGH but its diagnostic accuracy has not previously been assessed.

METHODS

First, we examined the reliability of asking about constipation compared with asking about Rome constipation criteria in inpatients treated with clozapine (n = 69). Second, we examined the diagnostic accuracy of (1) self-reported constipation and (2) the Rome criteria, compared with the reference standard of gastrointestinal motility studies.

RESULTS

After 30 motility tests, it was clear constipation screening had very poor diagnostic properties in this inpatient group and the study was terminated. Although 73% of participants had objective CIGH on motility testing, only 26% of participants self-reported constipation, with sensitivity of 18% (95% CI: 5-40%). Specificity and positive predictive values were higher (95% CI: 63-100% and 40-100%, respectively). Adding in Rome criteria improved sensitivity to 50% (95% CI: 28.2-71.8%), but half the cases were still missed, making this no more accurate than tossing a coin.

CONCLUSIONS

CIGH is often silent, with self-reported constipation having low sensitivity in its diagnosis. Treating CIGH based on self-reported symptoms questions will miss most cases. However, universal bowel motility studies are impractical. In the interests of patient safety, prophylactic laxatives are suggested for people taking clozapine.

Imaging Measurement of Whole Gut Transit Time in Paediatric and Adult Functional Gastrointestinal Disorders: A Systematic Review and Narrative Synthesis

BACKGROUND

functional gastrointestinal disorders (FGID) are common conditions in children and adults, often associated with abnormalities of whole gut transit. Currently, transit tests can be performed using several imaging methods, including tracking of radiopaque markers, gamma scintigraphy with the use of radioisotopes, magnetic tracking methods, tracking of movement of wireless motility capsules, and emerging magnetic resonance imaging (MRI) approaches.

OBJECTIVES

to review recent literature on diagnostic imaging techniques used to investigate whole gut transit in FGIDs.

METHODS

a systematic review was carried out. The different techniques are described briefly, with particular emphasis on contemporary literature and new developments, particularly in the field of MRI.

CONCLUSIONS

emerging MRI capsule marker methods are promising new tools to study whole gut transit in FGIDs.

Evaluation of gastric motility in nine dogs before and after prophylactic laparoscopic gastropexy: a pilot study

BACKGROUND

The purpose of this study was to evaluate the effect of a prophylactic laparoscopic gastropexy on gastric motility in healthy large-breed dogs.

METHODS

This was a prospective pilot study with nine healthy client-owned dogs. Each dog was its own control. Gastric motility was evaluated before and after laparoscopic gastropexy. Dogs were fed a standard diet three weeks before and after surgery. Gastric motility was measured before and 3 weeks after surgery. A wireless motility capsule (WMC) was used to measure gastric pH, intragastric pressure, temperature, frequency of contractions, motility index (MI) and transit time. Non-parametric statistical analysis was used to compare the paired data. Clients were contacted for follow-up information 2 years postoperatively.

RESULTS

Median frequency of gastric contractions was 1.3 (range, 0.6-1.9 contractions/min) before gastropexy and 1.0 (range, 0.3-2.6 contractions/min) after gastropexy (P = 0.820). Median MI was 49.2 (range, 23.7-96.6) before gastropexy and 28.1 (range, 12.2-148.9) after gastropexy (P = 0.652). Median gastric emptying time was 1140 (range, 486-1230 min) before gastropexy and 1110 (range, 306-2610 min) after gastropexy (P = 0.570). During the hour before the WMC passed through the pylorus, median MI was 72.2 (range, 48.2-549.3) before gastropexy and 52.9 (range, 15.20-322.8) after gastropexy (P = 0.734), and frequency of contractions was 1.1 (range, 0.9-4.1 contractions/min) before gastropexy and 1.2 (range, 0.5-3.0 contractions/min) after gastropexy (P = 0.652).

CONCLUSION

Motility in the stomach did not change in healthy dogs after prophylactic laparoscopic gastropexy. We conclude that preventive laparoscopic gastropexy does not induce gastroparesis.

Gastroparesis: a turning point in understanding and treatment

Gastroparesis is defined by delayed gastric emptying (GE) and symptoms of nausea, vomiting, bloating, postprandial fullness, early satiety and abdominal pain. Most common aetiologies include diabetes, postsurgical and postinfectious, but in many cases it is idiopathic. Clinical presentation and natural history vary by the aetiology. There is significant morbidity and healthcare utilisation associated with gastroparesis. Mechanistic studies from diabetic animal models of delayed GE as well as human full-thickness biopsies have significantly advanced our understanding of this disorder. An innate immune dysregulation and injury to the interstitial cells of Cajal and other components of the enteric nervous system through paracrine and oxidative stress mediators is likely central to the pathogenesis of gastroparesis. Scintigraphy and 13C breath testing provide the most validated assessment of GE. The stagnant gastroparesis therapeutic landscape is likely to soon see significant changes. Relatively newer treatment strategies include antiemetics (aprepitant), prokinetics (prucalopride, relamorelin) and fundic relaxants (acotiamide, buspirone). Endoscopic pyloromyotomy appears promising over the short term, especially for symptoms of nausea and vomiting. Further controlled trials and identification of the appropriate subgroup with pyloric dysfunction and assessment of long-term outcomes are essential. This review highlights the clinical presentation, diagnosis, mechanisms and treatment advancements for gastroparesis.

Influence of Gastric Emptying and Gut Transit Testing on Clinical Management Decisions in Suspected Gastroparesis

INTRODUCTION

Gastric emptying scintigraphy (GES) or wireless motility capsules (WMCs) can evaluate upper gastrointestinal symptoms in suspected gastroparesis; WMC tests can also investigate lower gut symptoms. We aimed to determine whether these tests impact treatment plans and needs for additional diagnostic evaluation.

METHODS

In a prospective, multicenter study, 150 patients with gastroparesis symptoms simultaneously underwent GES and WMC testing. Based on these results, investigators devised management plans to recommend changes in medications, diet, and surgical therapies and order additional diagnostic tests.

RESULTS

Treatment changes were recommended more often based on the WMC vs GES results (68% vs 48%) (P < 0.0001). Ordering of additional test(s) was eliminated more often with WMC vs GES (71% vs 31%) (P < 0.0001). Prokinetics (P = 0.0007) and laxatives (P < 0.0001) were recommended more often based on the WMC vs GES results. Recommendations for prokinetics and gastroparesis diets were higher and neuromodulators lower in subjects with delayed emptying on both tests (all P ≤ 0.0006). Laxatives and additional motility tests were ordered more frequently for delayed compared with normal WMC colonic transit (P ≤ 0.02). Multiple motility tests were ordered more often on the basis of GES vs WMC findings (P ≤ 0.004). Antidumping diets and transit slowing medications were more commonly recommended for rapid WMC gastric emptying (P ≤ 0.03).

DISCUSSION

WMC transit results promote medication changes and eliminate additional diagnostic testing more often than GES because of greater detection of delayed gastric emptying and profiling the entire gastrointestinal tract in patients with gastroparesis symptoms.

TRANSLATIONAL IMPACT

Gastric scintigraphy and WMCs have differential impact on management decisions in suspected gastroparesis.

Constipation in Peritoneal Dialysis Patients

Constipation in peritoneal dialysis (PD) is an infrequent but potentially serious condition affecting the mechanical properties of dialysis techniques and predisposing to bacterial intestinal translocation and eventual enteric peritonitis. Despite the importance of the problem, published literature is scarce, consisting mostly of uncontrolled single-center trials. This inconsistency may be attributed to the large number of clinical, radiological, and endoscopic tools that have been used in the studies with a lack of generally accepted core primary outcomes.

The current narrative review discusses the pathophysiological associations between chronic kidney disease, PD, and constipation with related complication.

Validation of Diagnostic and Performance Characteristics of the Wireless Motility Capsule in Patients With Suspected Gastroparesis

BACKGROUND & AIMS

It is a challenge to make a diagnosis of gastroparesis. There is good agreement in results from wireless motility capsule (WMC) analysis and gastric emptying scintigraphy (GES), but the diagnostic yield of WMC is unclear and the accuracy of this method has not been validated. We compared the performance characteristics of WMC vs GES in assessing gastric emptying in patients with suspected gastroparesis.

METHODS

We performed a prospective study of 167 subjects with gastroparesis (53 with diabetes and 114 without) at 10 centers, from 2013 through 2016. Subjects were assessed simultaneously by GES and with a WMC to measure gastric emptying and regional transit. Delayed gastric emptying by GES was defined as more than 10% meal retention at 4 hrs whereas delayed gastric emptying by WMC was defined as more than 5 hrs for passage of the capsule into the duodenum; a severe delay in gastric emptying was defined as a gastric emptying time of more than 12 hrs by WMC or more than 35% retention at 4 hrs by GES. Rapid gastric emptying was defined as less than 38% meal retention at 1 hr based on by GES or gastric emptying times less than 1:45 hrs by WMC. We compared diagnostic and performance characteristics of GES vs WMC.

RESULTS

Delayed gastric emptying was detected in a higher proportion of subjects by WMC (34.6%) than by GES (24.5%) (P=.009). Overall agreement in results between methods was 75.7% (kappa=0.42). In subjects without diabetes, the WMC detected a higher proportion of subjects with delayed gastric emptying (33.3%) than GES (17.1%) (P < .001). A higher proportion of subjects with diabetes had delayed gastric emptying detected by GES (41.7%) compared with non-diabetic subjects (17.1%) (P=.002). Severe delays in gastric emptying were observed in a higher proportion of subjects by WMC (13.8%) than by GES (6.9%) (P = .02). Rapid gastric emptying was detected in a higher proportion of subjects by GES (13.8%) than by WMC (3.3%) (P < .001). Regional and generalized transit abnormalities were observed in 61.8% subjects and only detected by WMC.

CONCLUSION

Although there is agreement in analysis of gastric emptying by GES vs WMC, WMC provides higher diagnostic yield than GES. WMC detects delayed gastric emptying more frequently than GES and identifies extra-gastric transit abnormalities. Diabetic vs non-diabetic subjects have different results from GES vs WMC. These findings could affect management of patients with suspected gastroparesis. ClinicalTrials.gov no: NCT02022826.

Is gastroparesis a gastric disease?

BACKGROUND

Gastroparesis is a digestive syndrome characterized by delayed gastric emptying (GE) and by symptoms that are suggestive of gastroduodenal motor disorders. There are three grades of gastroparesis of increasing severity: (a) mild gastroparesis; (b) compensated gastroparesis; and (c) gastric failure. GE abnormalities are partially related to symptom type and severity, and other mechanisms may be involved.

AIM

To investigate enteric dysmotility (ED) in patients with suspected gastroparesis.

METHODS

Patients with symptoms suggestive of gastroparesis were consecutively included in the study and underwent a ¹³ C-octanoic acid GE breath test and small bowel manometry (SBM). Clinical features were recorded using predefined, validated questionnaires at entry.

KEY RESULTS

The study enrolled 88 patients (71 women; mean age: 37.8 ± 14.3 years). Gastric emptying was delayed in 25 patients (28.4%), and 70 patients (79.5%) presented small bowel motor abnormalities including bursts, abnormal activity fronts, inability to respond to meal ingestion, and hypocontractility. Gastric emptying was delayed in 24 of the 70 patients with ED (34.3% vs 5.5% of patients with normal SBM). Enteric dysmotility was detected in 24 of 25 patients (96%) with delayed GE. Patients with and without delayed GE showed similar moderate/severe gastroparesis manifestations, but patients with ED significantly more often had moderate/severe gastroparesis manifestations than patients with normal SBM (grade 1:14% vs 39%, grade 2:62% vs 56%, grade 3:24% vs 5%, respectively).

CONCLUSIONS AND INFERENCES

Enteric dysmotility was more frequent than delayed GE in patients with symptoms suggestive of gastroparesis. Gastroparesis severity was associated with small bowel motor abnormalities but not with delayed GE.

GI Motility Testing: Stomach, Small Bowel, and Colon

Symptoms of abdominal pain, nausea, vomiting, bloating, abdominal distention, diarrhea, and constipation are common and may relate to abnormalities in gastrointestinal motility. There are a number of different options to study gastrointestinal motility. This article reviews novel and standard motility tests available in the stomach, small bowel, and colon. The indications for testing, technical details, advantages, and disadvantages of each test will be summarized.

More movement with evaluating colonic transit in humans

BACKGROUND

Colonic functions (ie, absorption of fluids and electrolytes, digestion of selected nutrients, harbor for microbes, and elimination of excreta) necessitate complex patterns of storage and transit. Indeed, colonic transit accounts for a major part of the mouth-to-anus transit time. Colonic transit assessments are useful for understanding the pathophysiology of disease, the pharmacodynamic effects of new medications and to diagnose slow transit constipation. Currently, radiopaque markers, scintigraphy, and a colonic pH-pressure capsule are used to measure overall colonic transit. Radioopaque markers, scintigraphy, and the electromagnetic capsule, which is a newer technique, also evaluate regional colonic transit. The pH-pressure capsule also measures colonic pressures. Magnetic resonance imaging and a radio-frequency identification-based device are evolving methods for assessing colonic transit.

PURPOSE

This mini-review, which accompanies a study evaluating the assessment of colon transit with the electromagnetic capsule, evaluates and compares existing and evolving methods for evaluating colonic transit in humans (Neurogastroenterol Motil. 2018; in press). In addition to overall and regional colonic transit, the electromagnetic capsule evaluates colonic motor patterns without radiation exposure. These patterns are summarized by analyzing the characteristics (ie, distance and velocity) of discrete antegrade and retrograde capsule movements as they travel in the colon. However, the electromagnetic capsule does not measure pressure or colonic wall movement (ie, contractions). The motor patterns identified by this capsule should be compared with motor patterns identified with manometry. The next challenge is to harness different techniques to evaluate the relationships between colonic pressures and transit or, even better, the trifecta of colonic contractions, pressure events, and transit.

Effects of Clozapine on the Gut: Cross-Sectional Study of Delayed Gastric Emptying and Small and Large Intestinal Dysmotility

BACKGROUND

Gastrointestinal hypomotility in people taking clozapine is common, poorly understood and potentially dangerous. It causes distress and sometimes sudden death, with greater associated morbidity than the better known adverse effect of clozapine, agranulocytosis. Neither the mechanism nor prevalence of clozapine-induced gastrointestinal hypomotility is well understood. Previous studies show clozapine impedes colon transit, likely owing to anticholinergic and anti-serotonergic properties. However, regional gastrointestinal transit times (including gastric and small bowel emptying) have not been quantified.

METHODS

We used wireless motility capsules to measure gastric emptying and small and large bowel transit times in clozapine-treated individuals. We tested 17 clozapine-treated patients without any known gastrointestinal dysfunction, and compared data with matched normative transit times.

RESULTS

Clozapine-treated participants had significant 'slow gut', with dysmotility in at least one region of the gastrointestinal tract evident in 82%, with 59% experiencing multi-regional dysmotility. Delayed gastric emptying was diagnosed in 41%, delayed small bowel transit in 71% and delayed colon transit in 50%. Only 18% of participants had normal studies. Hypomotility was not correlated with ethnicity, sex or duration of treatment. Subjective reporting of constipation had low sensitivity in predicting dysmotility. Delayed gastric emptying had been unrecognised clinically for all participants.

CONCLUSION

Clozapine is associated with significant multi-regional gastrointestinal dysfunction. This is relevant when considering the relationship between clozapine use and conditions such as gastroparesis, choking, aspiration pneumonia, constipation, ileus and intestinal pseudo-obstruction. While the constipating properties of clozapine are now well recognised, this study shows a high degree of vigilance is required for both lower and upper gastrointestinal dysmotility in people taking this antipsychotic.

Regional gastrointestinal pH profile is altered in patients with type 1 diabetes and peripheral neuropathy

BACKGROUND

Gastrointestinal (GI) symptoms, such as nausea and bloating, are common in people with type 1 diabetes (T1DM). Autonomic dysfunction can lead to changes in the GI secreto-motor function which can be associated with GI symptom development. We hypothesized that regional pH profiles in T1DM differs from health and would be associated with objective physiological/clinical markers.

METHODS

Forty-seven T1DM with confirmed diabetic sensory peripheral neuropathy and 41 healthy age-matched subjects underwent standardized wireless motility capsule testing. T1DM completed the gastroparesis cardinal symptom index (GCSI) and the gastrointestinal symptom rating scale. Disease duration, glycemic control, insulin usage, and 24-hour heart rate variability testing were evaluated.

KEY RESULTS

In comparison to healthy subjects, gastric, and large bowel median pH were lower in T1DM (1.8 ± 1.6 vs 2.9 ± 1.5, P = 0.001 and 6.7 ± 0.6 vs 7.0 ± 0.5, P = 0.003, respectively). Additionally, change in pH across the pylorus was lower while change in pH across the ileocecal junction was higher in T1DM (5.2 ± 1.5 vs 5.8 ± 0.5, P = 0.003 and 1.8 ± 0.4 vs 1.3 ± 0.4, P < 0.0001, respectively). No difference was found in small bowel median pH. Gastric median pH was associated with small bowel transit time (r = 0.30, P = 0.049). Change in pH across the pylorus was negatively associated with fasting glycose (r = -0.35, P = 0.027). Small bowel median pH was associated with nausea (r = 0.42, P = 0.005) and small bowel transit time (r = 0.48, P = 0.0007). Large bowel median pH was associated with nausea (r = 0.35, P = 0.018) and the total GCSI score (r = 0.34, P = 0.023).

CONCLUSIONS AND INFERENCES

The GI pH profile in T1DM with DSPN is different from healthy subjects. Changes in pH profile may have important therapeutic implications and influence pharmacotherapeutic bioavailability.

Small bowel fed response as measured by wireless motility capsule: Comparative analysis in healthy, gastroparetic, and constipated subjects

BACKGROUND

Small bowel fed response is an increased contractile activity pattern following the ingestion of a meal. Postprandial motility is traditionally evaluated using small bowel manometry. Wireless motility capsule (WMC) is an ingestible wireless capsule that measures pH, temperature, and intraluminal pressure. The primary aim of the study was to assess small bowel fed response captured with the non-invasive WMC. The secondary aim was to compare the fed response patterns between healthy subjects and patients with motility disorders of gastroparesis and constipation.

METHODS

All subjects had 250 cc Ensure^® meal 6 hours after WMC ingestion. Frequency of contractions (Ct), area under the curve (AUC), and motility index (MI) were analyzed during 30 minutes of pre-prandial baseline and 60 minutes postprandially in 20-minute windows.

KEY RESULTS

One hundred and eighty-eight subjects (107 healthy, 23 gastroparetics, 58 constipated) were analyzed. Healthy: Ct, AUC, and MI all increased significantly immediately after meal ingestion (P < .01). Motility parameters peak at 20-40 minutes postmeal. The motor activity decreased at the end of postprandial hour, but was still significantly higher than the fasting baseline (P < .01). Gastroparetics: All motility parameters failed to increase significantly compared to the baseline throughout the entire postprandial hour. Constipated: The fed response was similar to healthy subjects.

CONCLUSIONS AND INFERENCES

The small bowel fed response was readily observed in healthy and chronic constipation subjects with WMC but is blunted in gastroparetics. A blunted small bowel fed response suggests neuropathic changes outside the stomach and may contribute to postprandial symptoms.

Expert consensus document: Advances in the diagnosis and classification of gastric and intestinal motility disorders

Disturbances of gastric, intestinal and colonic motor and sensory functions affect a large proportion of the population worldwide, impair quality of life and cause considerable health-care costs. Assessment of gastrointestinal motility in these patients can serve to establish diagnosis and to guide therapy. Major advances in diagnostic techniques during the past 5-10 years have led to this update about indications for and selection and performance of currently available tests. As symptoms have poor concordance with gastrointestinal motor dysfunction, clinical motility testing is indicated in patients in whom there is no evidence of causative mucosal or structural diseases such as inflammatory or malignant disease. Transit tests using radiopaque markers, scintigraphy, breath tests and wireless motility capsules are noninvasive. Other tests of gastrointestinal contractility or sensation usually require intubation, typically represent second-line investigations limited to patients with severe symptoms and are performed at only specialized centres. This Consensus Statement details recommended tests as well as useful clinical alternatives for investigation of gastric, small bowel and colonic motility. The article provides recommendations on how to classify gastrointestinal motor disorders on the basis of test results and describes how test results guide treatment decisions.

Relating gastric scintigraphy and symptoms to motility capsule transit and pressure findings in suspected gastroparesis

BACKGROUND

Wireless motility capsule (WMC) findings are incompletely defined in suspected gastroparesis. We aimed to characterize regional WMC transit and contractility in relation to scintigraphy, etiology, and symptoms in patients undergoing gastric emptying testing.

METHODS

A total of 209 patients with gastroparesis symptoms at NIDDK Gastroparesis Consortium centers underwent gastric scintigraphy and WMCs on separate days to measure regional transit and contractility. Validated questionnaires quantified symptoms.

KEY RESULTS

Solid scintigraphy and liquid scintigraphy were delayed in 68.8% and 34.8% of patients; WMC gastric emptying times (GET) were delayed in 40.3% and showed 52.8% agreement with scintigraphy; 15.5% and 33.5% had delayed small bowel (SBTT) and colon transit (CTT) times. Transit was delayed in ≥2 regions in 23.3%. Rapid transit was rarely observed. Diabetics had slower GET but more rapid SBTT versus idiopathics (P ≤ .02). GET delays related to greater scintigraphic retention, slower SBTT, and fewer gastric contractions (P ≤ .04). Overall gastroparesis symptoms and nausea/vomiting, early satiety/fullness, bloating/distention, and upper abdominal pain subscores showed no relation to WMC transit. Upper and lower abdominal pain scores (P ≤ .03) were greater with increased colon contractions. Constipation correlated with slower CTT and higher colon contractions (P = .03). Diarrhea scores were higher with delayed SBTT and CTT (P ≤ .04).

CONCLUSIONS & INFERENCES

Wireless motility capsules define gastric emptying delays similar but not identical to scintigraphy that are more severe in diabetics and relate to reduced gastric contractility. Extragastric transit delays occur in >40% with suspected gastroparesis. Gastroparesis symptoms show little association with WMC profiles, although lower symptoms relate to small bowel or colon abnormalities.

Chronic constipation

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

Diabetes and the Stomach

OPINION STATEMENT

Longstanding diabetes mellitus (both type 1 and type 2) can impair gastric motor function and cause significant upper gastrointestinal symptoms which significantly degrade quality of life, cause nutritional deficits, and degrade healthcare resource use. The most commonly considered gut complication of diabetes, diabetic gastroparesis, is a syndrome of delayed gastric emptying in the absence of mechanical obstruction which leads to symptoms of nausea, vomiting, postprandial fullness, early satiation, bloating, and upper abdominal pain. Gastroparesis also can lead to loss of glycemic control. A diagnosis of gastroparesis is made by documenting delayed gastric emptying and excluding mechanical obstruction. Gastric emptying scintigraphy is the most commonly utilized test for the diagnosis of gastroparesis but novel tests of gastric function have recently been introduced including the gastric emptying breath test and wireless motility capsule. Management most often is aimed at controlling symptoms, which includes dietary modification, optimization of glycemic control, and medication therapy with prokinetics, antiemetics, and neuromodulatory agents. Endoscopic and/or surgical therapies may be considered for refractory cases of gastroparesis. Recent research has provided new insights into the pathophysiology of this disease and is characterizing potential benefits of novel therapeutic agents which show promise in the treatment of this condition. This article will review the pathophysiology, new insights into disease mechanism, and treatment options for diabetic gastroparesis.

Role of wireless motility capsule in the assessment and management of gastrointestinal dysmotility in patients with diabetes mellitus

BACKGROUND

Gastrointestinal (GI) dysmotility is common in diabetic patients. Wireless Motility Capsule (WMC) provides the transit profile of the entire GI tract in a single study. Factors affecting GI dysmotility and utility of WMC study are not clearly established in diabetic patients. Our aims were to study the pattern of GI dysmotility using WMC and evaluate the effect of glycemic control and presence of diabetic microvascular complications on motility impairment in diabetic patients. We also assessed the impact of WMC findings on clinical management.

METHODS

Retrospective chart review of all diabetic patients who underwent WMC testing at our institution from 2010 to 2015 was performed. Demographics, hemoglobinA1c levels, microvascular complications, and WMC findings were obtained. Impact of WMC on clinical management was assessed.

KEY RESULTS

A total of 100 patients were included. Mean age was 45±19 years and 76% were female. Seventy-two percentage had abnormal WMC testing, of which 29 (40%) had multiregional dysmotility. There were no significant differences in demographics, diabetic microvascular complications or hemoglobinA1c levels among patients with normal and abnormal WMC testing or among patients with isolated vs multiregional dysmotility. Information about subsequent clinical management was available for 47 patients. WMC testing was abnormal in 33 (70%) patients and treatment changes based on WMC results were made in 24 patients (73%).

CONCLUSIONS & INFERENCES

There was no association between hemoglobinA1c levels, microvascular complications and pattern of GI dysmotility in diabetic patients undergoing WMC. WMC testing lead to management changes in approximately 75% of diabetic patients with GI dysmotility.

Ingestible Sensors

Ingestible sensing capsules are fast emerging as a critical technology that has the ability to greatly impact health, nutrition, and clinical areas. These ingestible devices are noninvasive and hence are very attractive for customers. With widespread access to smart phones connected to the Internet, the data produced by this technology can be readily seen and reviewed online, and accessed by both users and physicians. The outputs provide invaluable information to reveal the state of gut health and disorders as well as the impact of food, medical supplements, and environmental changes on the gastrointestinal tract. One unique feature of such ingestible sensors is that their passage through the gut lumen gives them access to each individual organ of the gastrointestinal tract. Therefore, ingestible sensors offer the ability to gather images and monitor luminal fluid and the contents of each gut segment including electrolytes, enzymes, metabolites, hormones, and the microbial communities. As such, an incredible wealth of knowledge regarding the functionality and state of health of individuals through key gut biomarkers can be obtained. This Review presents an overview of the gut structure and discusses current and emerging digestible technologies. The text is an effort to provide a comprehensive overview of ingestible sensing capsules, from both a body physiology point of view as well as a technological view, and to detail the potential information that they can generate.

The Wireless Motility Capsule: a One-Stop Shop for the Evaluation of GI Motility Disorders

The wireless motility and pH capsule (WMC) provides an office-based test to simultaneously assess both regional and whole gut transit. Ingestion of this non-digestible capsule capable of measuring temperature, pH, and the pressure of its immediate surroundings allows for the measurement of gastric, small bowel, and colonic transit times in an ambulatory setting. Approved by the US Food and Drug Administration for the evaluation of suspected conditions of delayed gastric emptying and the evaluation of colonic transit in chronic idiopathic constipation, WMC should be considered in suspected gastrointestinal motility disorders as it provides a single study capable of simultaneously assessing for regional, multiregional, or generalized motility disorders. Specific indications for testing with the WMC should include the evaluation of suspect cases of gastroparesis, small bowel dysmotility, and slow transit constipation, as well as symptom syndromes suggestive of a multiregional or generalized gastrointestinal transit delay.

Utility of wireless motility capsule and lactulose breath testing in the evaluation of patients with chronic functional bloating

BACKGROUND

The precise aetiology of chronic bloating remains poorly understood and underlying gastroparesis, small bowel bacterial overgrowth and colonic inertia may, individually or collectively, play a role.

AIMS

In this retrospective cohort analysis of symptomatic patients with chronic persistent bloating, we determined the clinical utility of wireless motility capsule and lactulose breath test in further defining the underlying aetiology for functional bloating.

METHODS

Consecutive patients with chronic bloating underwent clinical assessment, wireless motility capsule testing and lactulose breath testing using standard protocols.

RESULTS

52 patients qualified for inclusion in this analysis, fulfilling Rome III criteria for functional bloating. Most patients (54%) had an abnormal wireless motility capsule study; of those, 11.5% had evidence of gastroparesis, 7.7% had small bowel transit delay, 15.8% had colonic inertia, 3.8% had delayed gastric and small bowel transit, 5.6% had combined gastric and colonic transit delay, 3.8% had delayed small bowel and colonic transit, and 5.6% had delayed gastric, small bowel and colon transit times. Using clinical questionnaires the median scores for bloating, constipation and eructation were not significantly different. Neither constipation nor eructation was specific to gastroparesis or colonic inertia but bloating was numerically more prevalent and severe in patients with delayed small bowel transit. 40% of patients had positive lactulose breath test but had no distinguishing clinical characteristics.

CONCLUSIONS

Chronic functional bloating may reflect underlying gastroparesis, small intestinal bacterial overgrowth or colonic inertia. Wireless motility capsule and lactulose breath test are useful in the assessment of patients with bloating and should be considered during evaluation.

SmartPill® as an objective parameter for determination of severity and duration of postoperative ileus: study protocol of a prospective, two-arm, open-label trial (the PIDuSA study)

INTRODUCTION

Postoperative ileus (POI) is a frequent complication after abdominal surgery (AS). Until today, neither a prophylaxis nor an evidence-based therapy exists. This originates from the absence of objective parameters evaluating the severity and duration of POI resulting in clinical trials of modest quality. The SmartPill(®), a capsule which frequently measures pH value, temperature and intraluminal pressure after swallowing, offers an elegant option for analysing gastrointestinal (GI) transit times and smooth muscle activity in vivo. As the use in patients in the first months after AS is not covered by the marketing authorisation, we aim to investigate the safety and feasibility of the SmartPill(®) immediately after surgery. Additionally, we analyse the influence of prokinetics and laxatives as well as standardised physiotherapy on postoperative bowel contractility, as scientific evidence of its effects is still lacking.

METHODS AND ANALYSIS

The PIDuSA study is a prospective, single-centre, two-arm, open-label trial. The SmartPill(®) will be applied to 55 patients undergoing AS having a high risk for POI and 10 patients undergoing extra-abdominal surgery rarely developing POI. The primary objective is the safety of the SmartPill(®) in patients after surgery on the basis of adverse device effects/serious adverse device effects (ADE/SADE). The sample size suggests that events with a probability of 3% could be seen with a certainty of 80% for at least once in the sample. Secondary objective is the analysis of postoperative intestinal activity in the GI tract in both groups. Furthermore, clinical signs of bowel motility disorders will be correlated to the data measured by the SmartPill(®) to evaluate its significance as an objective parameter for assessing POI severity. Additionally, effects of prokinetics, laxatives and physiotherapy on postoperative peristaltic activity recorded by the SmartPill(®) will be analysed.

ETHICS AND DISSEMINATION

The protocol was approved by the federal authority (94.1.05-5660-8976) and the local ethics committee (092/14-MPG). Findings will be disseminated through publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT02329912; Pre-results.

Is Gastroparesis Found More Frequently in Patients with Cystic Fibrosis? A Systematic Review

Cystic fibrosis (CF) is associated with different gastrointestinal motility disturbances and syndromes. We aim to assess gastric emptying in patients with CF compared to healthy controls by a systematic review of existing literature. Medical databases and abstracts from major gastroenterology and CF meetings were reviewed. Emptying times in CF patients were compared with healthy controls using random effects models. Subgroup analysis stratified results by age and diagnostic modality. Nineteen studies from 7 countries included 574 subjects (359 CF patients and 215 controls). Using pooled analysis frequency of gastroparesis was high (38%, 95% CI 30-45%) but results were highly dependent on the diagnostic modality. Delayed gastric emptying is more common in CF compared to general population. Scintigraphy identified rapid gastric emptying in a subgroup of CF patients, but this finding disappeared with adequate pancreatic enzyme replacement and after other diagnostic modalities were included.

Blunting of Colon Contractions in Diabetics with Gastroparesis Quantified by Wireless Motility Capsule Methods

Generalized gut transit abnormalities are observed in some diabetics with gastroparesis. Relations of gastric emptying abnormalities to colon contractile dysfunction are poorly characterized. We measured colon transit and contractility using wireless motility capsules (WMC) in 41 healthy subjects, 12 diabetics with gastroparesis (defined by gastric retention >5 hours), and 8 diabetics with normal gastric emptying (≤5 hours). Overall numbers of colon contractions >25 mmHg were calculated in all subjects and were correlated with gastric emptying times for diabetics with gastroparesis. Colon transit periods were divided into quartiles by time and contraction numbers were calculated for each quartile to estimate regional colon contractility. Colon transit in diabetics with gastroparesis was prolonged vs. healthy subjects (P<0.0001). Overall numbers of colon contractions in gastroparetics were lower than controls (P = 0.02). Diabetics with normal emptying showed transit and contraction numbers similar to controls. Gastric emptying inversely correlated with overall contraction numbers in gastroparetics (r = -0.49). Numbers of contractions increased from the 1^st to 4^th colon transit quartile in controls and diabetics with normal emptying (P≤0.04), but not gastroparetics. Numbers of contractions in the 3^rd and 4^th quartiles were reduced in gastroparetics vs. healthy controls (P≤0.05) and in the 4^th quartile vs. diabetics with normal emptying (P = 0.02). Numbers of contractions were greatest in the final 15 minutes of transit, but were reduced in gastroparetics vs. healthy controls and diabetics with normal emptying (P≤0.005). On multivariate analyses, differences in numbers of contractions were not explained by demographic or clinical variables. In conclusion, diabetics with gastroparesis exhibit delayed colon transit associated with reductions in contractions that are prominently blunted in latter transit phases and which correlate with delayed gastric emptying, while diabetics with normal emptying show no significant colonic impairments. These findings emphasize diabetic gastroparesis may be part of a generalized dysmotility syndrome.

A study of human colonic motility in healthy and constipated subjects using the wireless capsule

Constipation is a common and distressing condition that has been linked to major morbidity, burdens the health care system, and impacts patients׳ quality of life. However, there is no perfect method for diagnosing and treating constipation. The purpose of this paper is to develop an automatic algorithm to identify patients with constipation from healthy subjects. Data from 12 healthy subjects and 10 patients with constipation were analyzed. The key challenges for data processing were data filtering, feature extraction, information evaluation, and providing the reference conclusion; these were resolved by employing the phase space reconstruction (PSR), independent component analysis (ICA), dynamic feature extraction algorithm, and the Wilcoxon rank sum test. The contractile frequency (Fr), motility index per unit time (MIU), average peak of peristaltic wave (Pave) and variance (Var) were extracted as dynamic parameters and analyzed. Results between groups were compared with the Wilcoxon rank sum test. There were statistically significant differences between healthy subjects and patients with constipation for Fr and MIU (P<0.05), whereas there was no statistically difference for Var. Moreover, the Fr and MIU of patients with normal transit constipation (NTC) are significantly lower compared to healthy subjects, whereas patients with slow transit constipation (STC) did not show significant differences. The proposed algorithms were able to differentiate between healthy subjects and patients with constipation based on the colonic motility profiles.

Quantitative measurements in capsule endoscopy

This review summarizes several approaches for quantitative measurement in capsule endoscopy. Video capsule endoscopy (VCE) typically provides wireless imaging of small bowel. Currently, a variety of quantitative measurements are implemented in commercially available hardware/software. The majority is proprietary and hence undisclosed algorithms. Measurement of amount of luminal contamination allows calculating scores from whole VCE studies. Other scores express the severity of small bowel lesions in Crohn׳s disease or the degree of villous atrophy in celiac disease. Image processing with numerous algorithms of textural and color feature extraction is further in the research focuses for automated image analysis. These tools aim to select single images with relevant lesions as blood, ulcers, polyps and tumors or to omit images showing only luminal contamination. Analysis of motility pattern, size measurement and determination of capsule localization are additional topics. Non-visual wireless capsules transmitting data acquired with specific sensors from the gastrointestinal (GI) tract are available for clinical routine. This includes pH measurement in the esophagus for the diagnosis of acid gastro-esophageal reflux. A wireless motility capsule provides GI motility analysis on the basis of pH, pressure, and temperature measurement. Electromagnetically tracking of another motility capsule allows visualization of motility. However, measurement of substances by GI capsules is of great interest but still at an early stage of development.

Clinical utility of wireless motility capsule in patients with suspected multiregional gastrointestinal dysmotility

BACKGROUND

Patients with gastrointestinal (GI) dysmotility often experience overlapping upper and lower GI symptoms suggestive of multiregional involvement. Wireless motility capsule (WMC) provides a full GI tract transit profile and may be able to detect and diagnose multiregional dysmotility.

AIM

To determine the clinical utility and diagnostic yield of WMC in patients with upper and lower GI symptoms suggestive of multiregional GI dysmotility.

METHODS

Retrospective chart review of all patients who had undergone WMC testing for suspected multiregional GI dysmotility from January 2009 to December 2012 at our institution was performed. Information regarding demographics, symptoms, medication use, prior diagnostic studies, and results of WMC testing was collected.

RESULTS

A total of 161 patients were included in the analysis. Mean age was 43 ± 15 years, and 83 % were female. WMC was abnormal in 109 (67.7 %) subjects. Of these, 17 (15.6 %) patients had isolated delayed gastric emptying, 13 (11.9 %) patients had isolated delayed small bowel transit, and 25 (22.9 %) patients had isolated delayed large bowel transit. Multiregional dysmotility was diagnosed in 54 (49.5 %) patients. There was no significant difference in past medical or past surgical history between patients with isolated regional versus multiregional involvement. The presence or absence of various patient-reported symptoms by history did not predict an abnormal WMC study.

CONCLUSIONS

Patients' symptoms are poor predictors of GI dysmotility and its anatomical extent. WMC can be a useful diagnostic test in these patients as it provides a comprehensive evaluation of the motility profile of the entire GI tract and provides objective evidence of multiregional involvement.

Acceleration of small bowel transit in a canine hypermotility model with intestinal electrical stimulation

OBJECTIVE

Few studies have been performed on the effect of intestinal electrical stimulation (IES) on intestinal dysmotility. This study aimed to investigate the small intestine transit (SIT) in a canine model of intestinal hypermotility when applying IES.

METHOD

Six hound bitches were surgically prepared with two chronic intestinal fistulas, intestinal serosal electrodes of which the proximal pair was used for serosal IES. Pacing wires were attached to a manometric catheter for mucosal IES. A nitrogen oxide synthase inhibitor, Nω-nitro-L-arginine (LNNA) was used to induce intestinal motility. SIT was measured during IES. The study consisted of four randomized sessions: session 1 (LNNA), session 2 (LNNA plus serosal IES), session 3 (LNNA plus mucosal IES) and session 4 (control).

RESULTS

The intestine transit was slowed down from 31.7 ± 6.1 min in the control session to 49.0 ± 6.2 min after using LNNA (P = 0.003). Both mucosal and serosal IES accelerated SIT compared with the LNNA session. The SIT time was reduced to 17.7 ± 3.4 min in the mucosal IES session (P = 0.006 vs. LNNA) and 27.5 ± 6.3 min in the serosal IES session (P = 0.020 vs. LNNA). No difference was noted in the SIT time between mucosal and serosal IES (P = 0.128).

CONCLUSION

IES significantly accelerates delayed SIT in a hypermotility model and intraluminal stimulation is as effective as a serosal one for IES, suggesting that IES may have a therapeutic potential for improving intestinal motility.

The use of SmartPill for gastric monitoring

Testing to define delayed gastric emptying is required to diagnose gastroparesis; rapid emptying is found in other patients. Commonly performed methods of gastric emptying testing include scintigraphy and breath testing. The SmartPill wireless motility capsule (WMC) system is US FDA-approved for evaluating suspected delayed emptying in gastroparesis and functional dyspepsia. The device measures transit in the stomach, small intestine, and colon by detecting characteristic pH transitions; and quantifies pressure waves in each gut region. WMC gastric emptying times correlate with scintigraphic measures. Incremental benefits of WMC testing in patients with suspected gastroparesis include delineation of pressure abnormalities and small intestinal and colonic transit delays. Acceptance of trial data confirming usefulness of WMC testing in suspected gastric motor disorders has been hampered by small sample sizes and design limitations. Ongoing multicenter studies will validate the utility of WMC methods in patients with suspected gastroparesis and other upper gastrointestinal motor disorders.

Gastrointestinal motility revisited: The wireless motility capsule

INTRODUCTION

The wireless motility capsule (WMC) is a novel ambulatory technology that concurrently measures intraluminal pH, temperature, and pressure as it traverses the gastrointestinal tract.

OBJECTIVES

We aim to provide a concise summary of the WMC, detailing the procedure for its administration and the parameters it records. We also review the evidence that has validated the WMC against other methods currently regarded as 'gold standard'.

CONCLUSIONS

The WMC offers a number of advantages over and above current techniques, especially with respect to patient tolerability, safety, and standardization. The WMC represents a considerable enhancement of the researchers' and clinicians' investigatory armamentarium. If this technology becomes widely adopted, coupled with international consensus upon the interpretation of physiological data derived therein, it may herald a new and exciting era in gastrointestinal physiology.

How to assess regional and whole gut transit time with wireless motility capsule

Assessment of transit through the gastrointestinal tract provides useful information regarding gut physiology and patho-physiology. Although several methods are available, each has distinct advantages and limitations. Recently, an ingestible wireless motility capsule (WMC), similar to capsule video endoscopy, has become available that offers a less-invasive, standardized, radiation-free and office-based test. The capsule has 3 sensors for measurement of pH, pressure and temperature, and collectively the information provided by these sensors is used to measure gastric emptying time, small bowel transit time, colonic transit time and whole gut transit time. Current approved indications for the test include the evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalised dysmotility. Rare capsule retention and malfunction are known limitations and some patients may experience difficulty with swallowing the capsule. The use of WMC has been validated for the assessment of gastrointestinal transit. The normal range for transit time includes the following: gastric emptying (2–5 hours), small bowel transit (2–6 hours), colonic transit (10–59 hours) and whole gut transit (10–73 hours). Besides avoiding the use of multiple endoscopic, radiologic and functional gastrointestinal tests, WMC can provide new diagnoses, leads to a change in management decision and help to direct further focused work-ups in patients with suspected disordered motility. In conclusion, WMC represents a significant advance in the assessment of segmental and whole gut transit and motility, and could prove to be an indispensable diagnostic tool for gastrointestinal physicians worldwide.

Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults

BACKGROUND

The characterisation and management of chronic severe gastrointestinal (GI) dysmotility are challenging. It may cause intestinal failure requiring home parenteral nutrition (HPN).

AIMS

To review the presentation, aetiology, characterisation, management and outcome of chronic severe GI dysmotility, and to suggest a pragmatic management algorithm.

METHODS

PubMed search was performed up to December 2012 using appropriate search terms, restricted to human articles and reviewed for relevance. Segmental dysmotility, acute ileus, functional syndromes and non-English articles were excluded. Evidence and recommendations were evaluated using the GRADE system.

RESULTS

In total, 721 relevant articles were reviewed. A coherent and definitive picture is hampered by overlapping classification systems using multi-modal characterisation methods, subject to pitfalls and some requiring further validation. The literature is confined to case series with no randomised trials. Fewer than 20% undergo full thickness jejunal biopsy, which are otherwise labelled idiopathic. However, in studies with up to 80% biopsy rates, neuromuscular abnormalities may be found in 90%. Between 14% and 50% will require HPN, comprising 8-14% of all HPN patients, of which 2/3 are primary/idiopathic and 1/3 secondary, with scleroderma being the leading secondary cause. Ten-year  mortality ranges from 13% to 35% and is worst in elderly scleroderma patients. Management includes limited treatments for secondary causes, prokinetics, symptom palliation, psychological support, nutrition, hydration and judicious surgery.

CONCLUSIONS

Severe dysmotility often remains idiopathic. It is rarely possible to alter disease trajectory; consequently, prognosis may be poor. Multi-disciplinary teams in a specialist setting can improve outcomes. Graded recommendations are enumerated and a pragmatic algorithm is suggested.