Prevalence and predictors of delayed gastric emptying among Indian patients with long-standing type 2 diabetes mellitus

Prevalence of gastroparesis symptoms and its associated factors among type 2 diabetes mellitus patients in West Bank in Palestine: a national cross-sectional study

Introduction

Diabetic gastroparesis (DGP) is defined as delayed gastric emptying without any mechanical obstruction in diabetic patients.

Methods

We conducted a cross-sectional study using an Arabic-validated translated version of the Gastroparesis Cardinal Symptom Index (GCSI). A total of 3,542 diabetic patients were interviewed, of whom 91.6% were finally included in the analysis.

Results

DGP symptoms were present in 14.5% of the study population, of which 10.2% had a GCSI score of severe disease. Further analysis of individuals with GCSI scores≥1.9 (14.5%; 470) revealed that 50.8% of them visited a doctor at least once, and 18% had been hospitalized due to DGP symptoms. However, only nine patients (1.9%) were diagnosed with DGP. The most common symptoms were stomach fullness and early satiety. The binary regression model showed that DGP symptoms were more likely to occur in patients who had diabetes for >10 years and glycosylated hemoglobin >9. Furthermore, the model revealed that females were at a higher risk of developing DGP.

Discussion

This was the first study in Palestine on DGP, which showed that the condition is underdiagnosed. This is not only because of the unavailability of standard diagnostic methods but also due to the under appreciation of gastrointestinal complaints in diabetic patients.

Prokinetic effect of erythromycin in the management of gastroparesis in critically ill patients-our experience and literature review

Introduction

Gastroparesis is a disorder characterized by impaired gastric emptying and the accumulation of food in the intestines without any clear mechanical cause. Gastroparesis in critical care patients is a prevalent issue in the intensive care unit. The disruption of normal gastrointestinal motility in critically ill patients is linked to a significant risk of intolerance to enteral feeding, colonization of the gastrointestinal tract with pathogenic bacterial strains, increased permeability of the intestinal wall, translocation of the intestinal microbiota, leading to progressive malnutrition, and potential development of bacterial infection.

Materials and methods

The literature was reviewed to assess the benefits and risks associated with the use of this medication.

Aim

The aim of the study was to treat the symptoms of gastroparesis and stimulate gastrointestinal motility. Consequently, the aim was to reduce the amount of backed-up food content in the stomach, accelerate gastrointestinal motility, and return to intestinal feeding.

Results

Gastroparesis is a frequent issue among patients in the intensive care unit. Critical illness can lead to gastrointestinal motility disorders, causing slowed gastric emptying. This increases the risk of problems such as intolerance to enteral feeding, regurgitation, and aspiration of gastrointestinal contents into the respiratory tract, as well as colonization of the gastrointestinal tract by pathogens. Over time, impaired intestinal absorption can result in malnutrition, necessitating the initiation of parenteral nutrition.

Conclusion

After analysis of the literature and published scientific reports, as well as considering their own research, it is evident that erythromycin, as a prokinetic drug, effectively enhances gastrointestinal motility. This contributes to stimulating gastric emptying in critically ill patients with gastroparesis who are hospitalized in an intensive care unit. The use of erythromycin in combination with metoclopramide and/or itopride hydrochloride allows for a synergistic effect, leading to the quickest possible return to enteral feeding.

Gastric emptying is slower in women than men with type 2 diabetes and impacts on postprandial glycaemia

AIM

To evaluate sex differences in gastric emptying and the glycaemic response to a glucose drink and a high carbohydrate meal in type 2 diabetes (T2D).

METHODS

In cohort 1, 70 newly diagnosed, treatment-naïve Chinese patients with T2D (44 men) recruited from a diabetes outpatient clinic ingested a 75-g glucose drink containing 150 mg 13C-acetate. In cohort 2, 101 Australian patients with T2D (67 male) recruited from the community, managed by diet and/or metformin monotherapy, ingested a semi-solid mashed potato meal, labelled with 100 μl 13C-octanoic acid. Breath samples were collected over 3 and 4 h, respectively, for assessment of gastric emptying, and venous blood was sampled for evaluation of glycaemia (with and without adjustment for each participant's estimated total blood volume).

RESULTS

Gastric emptying was slower in female than male subjects in both cohorts (both p < .01). Multiple linear regression analyses revealed that gastric emptying was independently associated with sex (both p < .05). Without adjustment for blood volume, the glycaemic responses to oral glucose and the mixed meal were greater in female subjects (both p < .001). However, after adjustment for blood volume, the glycaemic responses were greater in men (both p < .05).

CONCLUSIONS

Gastric emptying is slower in women than men with T2D, associated with a reduced blood volume-adjusted glycaemic response to oral glucose and a mixed meal in women. These observations highlight the sex difference in postprandial glucose handling, which is relevant to the personalized management of postprandial glycaemia in T2D.

Factors Associated With Delayed Gastric Emptying in Symptomatic Diabetic and Non-diabetic Patients: A Retrospective Observational Study

Background Gastroparesis, characterized by delayed gastric emptying without mechanical obstruction, is a significant complication, especially in diabetic individuals. It manifests through symptoms such as abdominal bloating, feelings of fullness, and pain. This study investigates the prevalence of gastroparesis among non-diabetic and diabetic patients, exploring associations with demographic data, hemoglobin A1C (HbA1C) levels, and symptoms. Methodology This retrospective, observational, cohort study included patients with gastroparesis symptoms who underwent a nuclear gastric emptying study from January 2021 to April 2023. The study analyzed demographic data, symptoms, and HbA1c levels to identify correlations with delayed gastric emptying. Results Of 157 patients, 34.4% exhibited delayed gastric emptying. Diabetic patients comprised 29.3% of the sample, with a notable disease duration of over 10 years in 77.3% of cases. Symptoms such as nausea, vomiting, epigastric pain, and early satiety were prevalent, with significant associations between delayed emptying and female gender, higher HbA1c, and vomiting. Conclusions Delayed gastric emptying is significantly associated with female gender, elevated HbA1c levels, and when vomiting is the presenting symptom. Highlighting the importance of awareness among healthcare providers and the community, the findings encourage collaborative efforts for further gastroparesis research to better understand the predictive factors and mechanisms.

Impaired gastric accommodation in patients with postprandial distress syndrome type of functional dyspepsia assessed by 2D ultrasonography

BACKGROUND AND PURPOSE

The pathophysiology of postprandial distress syndrome includes impaired gastric accommodation, hypersensitivity to gastric distension and delayed gastric emptying. 2D-ultrasonography is one of the methods to assess gastric accommodation by measuring proximal gastric area and we evaluated its role in calculating proximal gastric area and thus assessing gastric accommodation in Indian patients with postprandial distress syndrome.

METHODS

In a hospital-based comparative analysis, proximal gastric area was measured with 2D-ultrasonography of postprandial distress syndrome (PDS) patients and compared with healthy controls. Five readings were measured every five minutes till 25 minutes after 400 mL of vegetable soup. The Patient Assessment of Upper Gastrointestinal Disorders-Quality of Life (PAGI-QOL score) and diets aggravating PDS symptoms were studied through detailed questionnaires. Sample size was calculated at 80% study power and alpha error of 0.05 to be 30 subjects in each group.

RESULTS

The mean age of patients (18 males) vs. 30 healthy controls (25 males) was 40.8 ± 11.50 years vs. 36.37 ± 7.58, respectively, (p = 0.084). Proximal gastric area was significantly lower in patients versus healthy controls at five minutes (22.54 ± 2.77 vs. 30.66 ± 2.55 cm2), 10 minutes (23.03 ± 2.45 vs. 31.10 ± 2.06 cm2), 15 minutes (23.06 ± 2.27 vs. 30.31 ± 2.11 cm2), 20 minutes (22.21 ± 2.31 vs. 29.73 ± 1.71 cm2) and 25 minutes (22.02 ± 2.33 vs. 28.39 ± 1.55 cm2); p < 0.001 at all intervals of time, indicating impaired gastric accommodation. The QOL was poor in all patients with PDS with mean PAGI-QOL score of 31.30 ± 15.05, median of 30, minimum score of 12 and maximum score of 66.

CONCLUSIONS

Measurement of proximal gastric area with 2D-ultrasonography is simple and non-invasive. Proximal gastric area in patients was lower than controls, indicating impaired gastric accommodation. Poor quality of life was universal in patients with postprandial distress syndrome.

Assessment of Gastric Dysmotility Using Standardized Tc-99m Sulfur Colloid-Labeled Rice Cakes in Diabetic Patients

Background

Diabetes mellitus is a common lifestyle disease where patients suffer from gastric dysmotility, which is usually underdiagnosed. The aim of this study was to evaluate the utility of Tc-99m sulfur colloid-labeled meal gastric emptying scintigraphy in Type 2 diabetic patients.

Methods

A total of 43 patients and 30 controls, satisfying the inclusion criteria from March 2019 to August 2020, were included. Serial planar images were acquired in both anterior and posterior projections for an iso-time of 1 min at 1 min, 60 min (1 h), 120 min (2 h), and 240 min (4 h) after consumption of Tc-99m SC-labeled idly (rice cakes). The gastric emptying was considered delayed if there was <10% emptying at 1 h, <70% emptying at 2 h, and <94% emptying at 4 h.

Results

The mean T1/2 was similar among cases (44.11 ± 10.52 min) and controls (49.56 ± 13.44 min, P = 0.056) while the mean gastric emptying at 1 h was slower in cases compared to controls, P = < 0.01. Two cases (4.6%) had delayed gastric emptying while none of the controls had delayed gastric emptying. T1/2 showed no association with duration of diabetes or HbA1c levels (P = 0.76, 0.45) and a weak correlation with fasting blood sugar (FBS) on the day of scan (R value = 0.18).

Conclusion

In comparison to controls, diabetic patients had faster gastric emptying with no association with duration of diabetes or HbA1c levels and a weak correlation with FBS on the day of scan.

Comparison of gastric motility in patients of type 2 diabetes mellitus with various degrees of glycemic control

The aim of this study was to evaluate the effect of glycemic control as estimated by glycated hemoglobin A1c (HbA1c) on gastric emptying in patients with type 2 diabetes mellitus (DM) using gastric emptying scintigraphy (GES). This was a cross-sectional study conducted at a tertiary health care center in Northern India. The study included 44 patients who underwent GES using a radiolabeled solid Idli meal containing 1 mCi of Tc-99 m Sulfur Colloid. Patients were divided into three groups based on glycemic control as Group A, B, and C with HbA1c <7%, 7%–9%, and >9%. Statistical analysis was performed using the IBM® SPSS® Statistics Version 23.0 The comparison of proportions was done using the Chi-square test and Fisher's exact test. Means were compared using the independent t-test and one-way analysis of variance. P < 0.05 was considered statistically significant. No statistically significant correlation was found between delayed gastric emptying and glycemic control (P = 0.09), gender (P = 0.228), dietary patterns (P = 0.91), symptoms of gastroparesis (P = 0.06), body mass index (BMI) (P = 0.267), and duration of type 2 DM (P = 0.565). No statistically significant association was also found between glycemic control and time taken for half gastric emptying (t1/2) (P = 0.225). Scintigraphy using Tc-99m Sulfur Colloid radiolabeled Idli meal can be effectively used for the assessment of gastric emptying. There is no significant correlation of delayed gastric emptying with glycemic control, gender, BMI, type of diet, and duration of diabetes mellitus.

Rapid, non-invasive measurement of gastric emptying rate using transcutaneous fluorescence spectroscopy

Gastric emptying rate (GER) signifies the rate at which the stomach empties following ingestion of a meal and is relevant to a wide range of clinical conditions. GER also represents a rate limiting step in small intestinal absorption and so is widely assessed for research purposes. Despite the clinical and physiological importance of gastric emptying, methods used to measure GER possess a series of limitations (including being invasive, slow or unsuitable for certain patient populations). Here, we present a new technique based on transcutaneous (through-the-skin) fluorescence spectroscopy that is fast, non-invasive, and does not require the collection of samples or laboratory-based analysis. Thus, this approach has the potential to allow immediate reporting of clinical results. Using this new method, participants receive an oral dose of a fluorescent contrast agent and a wearable probe detects the uptake of the agent from the gut into the blood stream. Analysis of the resulting data then permits the calculation of GER. We compared our spectroscopic technique to the paracetamol absorption test (a clinically approved GER test) in a clinical study of 20 participants. Results demonstrated good agreement between the two approaches and, hence, the clear potential of transcutaneous fluorescence spectroscopy for clinical assessment of GER.

Delayed Gastric Emptying among Indian Patients with Non-Diabetic Chronic Kidney Disease

Introduction:

Upper gastrointestinal symptoms such as nausea, vomiting, abdominal bloating, and poor appetite are more frequent among chronic kidney disease (CKD) patients and may contribute to poor nutritional intake and malnutrition. Delayed gastric emptying (GE), one of the important contributors to these symptoms, has not been evaluated systematically in different stages of non-diabetic CKD, among Indian patients.

Materials and Methods:

This hospital-based, cross-sectional analytical study aimed to find out the frequency of delayed GE in non-diabetic CKD (stages: 3,4,5) patients and also to study the correlation between delayed GE and symptoms of gastroparesis, autonomic neuropathy and nutritional parameters. Patients were subjected to evaluation of symptoms of gastroparesis by standardized questionnaire (gastroparesis cardinal symptom index), nutritional status (by anthropometric measures and serum albumin), autonomic function by heart rate variability (HRV) and GE by gastric scintigraphy with a standardized solid rice idli (savory cake) meal labeled with technetium-99m sulfur colloid.

Results:

Of the 89 non-diabetic CKD (stages-3,4,5) patients evaluated, 22 (≈25%) had delayed GE and 8 (≈9%) rapid GE. Prevalence of delayed GE was higher among stage 5 (15/49, 31%) compared to stages 3 and 4 (7/40, 17.5%), though the difference was statistically insignificant. There was no association between delayed GE and symptoms of gastroparesis and autonomic neuropathy. Though not statistically significant, nutritional parameters (body mass index, skinfold thickness, and serum albumin) were poorer in the delayed GE group compared to the rest.

Conclusion:

Delayed GE, irrespective of symptoms, may contribute to malnutrition and hence should be looked for in non-diabetic CKD patients with unexplained malnutrition.

Knowledge, Attitude, and Practice Survey of Gastroparesis in Asia by Asian Neurogastroenterology and Motility Association

BACKGROUND/AIMS

Gastroparesis is identified as a subject that is understudied in Asia. The scientific committee of the Asian Neurogastroenterology and Motility Association performed a Knowledge, Attitude, and Practices survey on gastroparesis among doctors in Asia.

METHODS

The questionnaire was created and developed through a literature review of current gastroparesis works of literature by the scientific committee of Asian Neurogastroenterology and Motility Association.

RESULTS

A total of 490 doctors from across Asia (including Bangladesh, China, Hong Kong, Indonesia, Japan, Malaysia, Myanmar, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam) participated in the survey. Gastroparesis is a significant gastrointestinal condition. However, a substantial proportion of respondents was unable to give the correct definition and accurate diagnostic test. The main reason for lack of interest in diagnosing gastroparesis was "the lack of reliable diagnostic tests" (46.8%) or "a lack of effective treatment" (41.5%). Only 41.7% of respondents had access to gastric emptying scintigraphy. Most doctors had never diagnosed gastroparesis at all (25.2%) or diagnosed fewer than 5 patients a year (52.1%).

CONCLUSIONS

Gastroparesis can be challenging to diagnose due to the lack of instrument, standardized method, and paucity of research data on normative value, risk factors, and treatment studies in Asian patients. Future strategies should concentrate on how to disseminate the latest knowledge of gastroparesis in Asia. In particular, there is an urgent need to estimate the magnitude of the problems in high risk and idiopathic patients as well as a standardized diagnostic procedure in Asia.

Symptoms Suggestive of Gastroparesis in a Community-Based Cohort of European Americans and African Americans with Type 2 Diabetes Mellitus

BACKGROUND

Although gastroparesis is seen in patients with type 2 diabetes mellitus (T2DM), the prevalence of symptoms suggestive of gastroparesis in patients with T2DM is unknown, particularly among African Americans.

AIMS

To determine the prevalence of symptoms associated with gastroparesis in a large community-based population of European Americans and African Americans with T2DM.

METHODS

Individuals with T2DM in the Diabetes Heart Study were asked to complete the gastroparesis cardinal symptom index (GCSI) and other GI-related questionnaires. GCSI total score ≥ 18 represented moderate or worse symptoms suggestive of gastroparesis.

RESULTS

A total of 1253 participants (700 female, 553 male) completed the GCSI: 750 were European American and 503 African American. GCSI scores ≥ 18 were recorded in 72 participants: 38 (5%) of European Americans and 34 (7%) of African Americans. The average GCSI was 24.1 in European Americans and 24.6 in African Americans, indicating moderate to severe symptoms. Compared to European Americans with GCSI scores ≥ 18, African Americans were younger (59.4 vs. 53.3 years, p = 0.004), had earlier onset of T2DM (46.3 vs. 40.1 years, p = 0.01), higher HbA1c (7.6 vs. 9.1, p = 0.0009), underwent fewer upper endoscopies (55.3% vs. 26.5%, p = 0.02), and had more anxiety and depression (p < 0.001).

CONCLUSIONS

Moderate or greater symptoms suggestive of gastroparesis are present in 5-7% of European and African American patients with T2DM in community-based populations. Symptoms suggestive of gastroparesis may be underappreciated in patients with T2DM and account for upper gastrointestinal symptoms, unexplained glycemic control issues, and decreased quality of life.

Gastroparesis in the 2020s: New Treatments, New Paradigms

PURPOSE OF REVIEW

This review highlights recent work that will lead to near-term advances in the understanding and treatment of gastroparesis (Gp).

RECENT FINDINGS

Major current advancements in the pathophysiology of Gp, include recognition of the SIP syncytium as the pacemaking unit rather than ICC alone and that Gp may be part of a pan-enteric autoimmune and/or autonomic disorder with macrophage imbalance. The development of newer techniques to assess gastric emptying (gastric emptying breath test and wireless motility capsule) and pyloric distensibility (EndoFLIP®) are allowing clinicians better characterization of their patients. In addition to pharmaceutical compounds in the pipeline, neuromodulation and endosurgical techniques, such as G-POEM, may help address refractory Gp. We expect that the 2020 decade will witness exciting developments. Treatments targeting gastrointestinal motility, immunological dysfunction, and inflammatory mediators will be evaluated. We anticipate future studies will be guided by biomarkers correlated with patient outcomes and therapeutic efficacy to establish new paradigms in the management of Gp.

Role of Gastric Emptying in Symptoms of Gastroparesis

The symptoms of gastroparesis, such as nausea, vomiting, postprandial fullness, early satiety and abdominal pain, frequently impair the quality of life of the affected individuals. The diagnosis of gastroparesis is made after structural etiologies are ruled out and an assessment of gastric function shows delayed gastric emptying. The role of the delay in gastric emptying in the pathogenesis of symptoms of gastroparesis has been debated, with some studies suggesting an association between delayed gastric emptying and the upper gastrointestinal symptoms, while others do not. The recent literature supports the importance of using reliable methods to assess gastric emptying, as delay in gastric emptying measured on a reliable test (4-h scintigraphy or breath test) is associated with the severity of upper gastrointestinal symptoms. In addition to measuring total gastric emptying, evaluation of regional gastric retention in the proximal and distal stomach and whole gut transit to assess small intestinal and colonic transit may provide additional useful information in patients with more generalized symptoms of gastrointestinal dysmotility.

Association between delayed gastric emptying and upper gastrointestinal symptoms: a systematic review and meta-analysis

BACKGROUND

The relationship between delayed gastric emptying and upper GI symptoms (UGI Sx) is controversial.

OBJECTIVE

To assess association between gastric emptying and UGI Sx, independent of treatment.

DESIGN

We performed a systematic review and meta-analysis of the literature from 2007 to 2017, review of references and additional papers identified by content expert. We included studies evaluating the association between gastric emptying and nausea, vomiting, early satiety/postprandial fullness, abdominal pain and bloating. Covariate analyses included optimal gastric emptying test method, gastric emptying type (breath test or scintigraphy) and patient category. Meta-regression compared the differences based on type of gastric emptying tests.

RESULTS

Systematic review included 92 gastric emptying studies (26 breath test, 62 scintigraphy, 1 ultrasound and 3 wireless motility capsule); 25 of these studies provided quantitative data for meta-analysis (15 scintigraphy studies enrolling 4056 participants and 10 breath test studies enrolling 2231 participants). Meta-regression demonstrated a significant difference between optimal and suboptimal gastric emptying test methods when comparing delayed gastric emptying with nausea and vomiting. On evaluating studies using optimal gastric emptying test methodology, there were significant associations between gastric emptying and nausea (OR 1.6, 95% CI 1.4 to 1.8), vomiting (OR 2.0, 95% CI 1.6 to 2.7), abdominal pain (OR 1.5, 95% CI 1.0 to 2.2) and early satiety/fullness (OR 1.8, 95% CI 1.2 to 2.6) for patients with UGI Sx; gastric emptying and early satiety/fullness in patients with diabetes; gastric emptying and nausea in patients with gastroparesis.

CONCLUSIONS

The systematic review and meta-analysis supports an association between optimally measured delayed gastric emptying and UGI Sx.

Diabetic Gastroparesis: Principles and Current Trends in Management

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.

Assessment of the Prevalence of Diabetic Gastroparesis and Validation of Gastric Emptying Scintigraphy for Diagnosis

OBJECTIVE

Gastroparesis is defined as delayed gastric emptying and is a common medical condition in diabetic patients. Scintigraphy is commonly used as a standard diagnostic procedure for the quantitative assessment of gastroparesis. The aims of this study were to determine an optimum imaging time for the diagnosis of gastroparesis, to assess the prevalence of gastroparesis, to evaluate the correlation between endoscopy and scintigraphy findings as well as the correlation between gastric emptying with patient genders, blood glucose concentration, and functional dyspepsia.

METHODS

Gastric emptying was assessed in 50 diabetic patients with a mean age of 50.16 years. For evaluation of gastric emptying, a test meal containing 2 pieces of toast, 120 cc non-labeled water and fried egg labeled with 1 mCi of 99mTc was given to each patient. The scintigraphy was performed immediately after ingestion and was repeated at 1, 1.5, 2 and 4 hours after ingestion. In some patients, an additional 90-minute dynamic scan was also acquired.

RESULTS

The prevalence of gastroparesis in this study population was determined as 64%. Also, the results of this study revealed that a 4-hour scan after ingestion is more relevant than a 90-minute dynamic scan for the evaluation of delayed gastric emptying. There was no statistically significant difference between 1-hour and 2-hour scans, 1-hour and 90-minute scans, 2-hour and 90-minute scans, 2-hour and 4-hour scans. Likewise there was no significant correlation between blood glucose levels, gender and calculated values of gastric emptying time in all groups.

CONCLUSION

According to our findings, it can be suggested that the prevalence of gastroparesis is higher than that mentioned in some previous studies. Also, this study indicates that a gastric emptying scintigraphy at 2 and 4 hours after meal ingestion might provide the anticipated clinical information in diabetic patients with dyspepsia without other evident reasons.