Gastric emptying in patients with Type 2 diabetes mellitus and diabetes associated with mitochondrial DNA 3243 mutation using 13C-octanoic acid breath test

Electrogastrography in Adult Gastroparesis: A Systematic Review and Meta-Analysis

BACKGROUND

Gastroparesis is a delay in gastric emptying without mechanical obstruction, lacking a clear pathophysiological mechanism, but with multiple histological abnormalities including loss of interstitial cells of Cajal, which may alter slow waves. We can assess slow waves with electrogastrography.

OBJECTIVES

To determine the prevalence and range of abnormalities in gastric slow waves in adults with gastroparesis using electrogastrography.

METHODS

We systematically searched Medline, Embase, LILACS, Web of Science, and Cochrane Register of Controlled Trials. We included studies with patients older than 18 years with gastroparesis, assessed using electrogastrography. We evaluated the percentage of duration of the recording in which the dominant power was in normogastria, tachygastria, and bradygastria; dominant frequency; power ratio; change in post-stimulus dominant power; and dominant frequency instability coefficient. Methodological quality was assessed using the Joanna Briggs Institute tool. Data were synthesized using narrative summary and meta-analysis.

RESULTS

A total of 3730 articles were reviewed, including 31 articles with 1545 patients and 340 controls. Compared to controls, gastroparetics patients had less normogastria (fasting: 50.3% versus 65.8%) (post-stimulus: 54.3% versus 66.5%), more bradygastria (fasting: 37.7% versus 13%) (post-stimulus: 31.9% versus 16.3%), and more tachygastria (fasting: 16.1% versus 4.6%) (post-stimulus: 18.3% versus 5.2%). Gastroparetics had less change in post-stimulus dominant power (1.45 dB versus 5.03 dB) and less power ratio (1.4 versus 5.26).

CONCLUSIONS

Gastroparetic patients present abnormalities in the frequency and changes in the post-stimulus power of slow waves, possibly secondary to a reduced number of interstitial cells of Cajal, as described in these patients.

Electrogastrography measurement systems and analysis methods used in clinical practice and research: comprehensive review

Electrogastrography (EGG) is a non-invasive method with high diagnostic potential for the prevention of gastroenterological pathologies in clinical practice. In this study, a review of the measurement systems, procedures, and methods of analysis used in electrogastrography is presented. A critical review of historical and current literature is conducted, focusing on electrode placement, measurement apparatus, measurement procedures, and time-frequency domain methods of filtration and analysis of the non-invasively measured electrical activity of the stomach. As a result, 129 relevant articles with primary aim on experimental diet were reviewed in this study. Scopus, PubMed, and Web of Science databases were used to search for articles in English language, according to the specific query and using the PRISMA method. The research topic of electrogastrography has been continuously growing in popularity since the first measurement by professor Alvarez 100 years ago, and there are many researchers and companies interested in EGG nowadays. Measurement apparatus and procedures are still being developed in both commercial and research settings. There are plenty variable electrode layouts, ranging from minimal numbers of electrodes for ambulatory measurements to very high numbers of electrodes for spatial measurements. Most authors used in their research anatomically approximated layout with two++ active electrodes in bipolar connection and commercial electrogastrograph with sampling rate of 2 or 4 Hz. Test subjects were usually healthy adults and diet was controlled. However, evaluation methods are being developed at a slower pace, and usually the signals are classified only based on dominant frequency. The main review contributions include the overview of spectrum of measurement systems and procedures for electrogastrography developed by many authors, but a firm medical standard has not yet been defined. Therefore, it is not possible to use this method in clinical practice for objective diagnosis.

Systematic Review Registration

https://www.prisma-statement.org/.

Gastrointestinal manifestations of mitochondrial disorders: a systematic review

Mitochondrial disorders (MIDs) due to respiratory-chain defects or nonrespiratory chain defects are usually multisystem conditions [mitochondrial multiorgan disorder syndrome (MIMODS)] affecting the central nervous system (CNS), peripheral nervous system, eyes, ears, endocrine organs, heart, kidneys, bone marrow, lungs, arteries, and also the intestinal tract. Frequent gastrointestinal (GI) manifestations of MIDs include poor appetite, gastroesophageal sphincter dysfunction, constipation, dysphagia, vomiting, gastroparesis, GI pseudo-obstruction, diarrhea, or pancreatitis and hepatopathy. Rare GI manifestations of MIDs include dry mouth, paradontosis, tracheoesophageal fistula, stenosis of the duodeno-jejunal junction, atresia or imperforate anus, liver cysts, pancreas lipomatosis, pancreatic cysts, congenital stenosis or obstruction of the GI tract, recurrent bowel perforations with intra-abdominal abscesses, postprandial abdominal pain, diverticulosis, or pneumatosis coli. Diagnosing GI involvement in MIDs is not at variance from diagnosing GI disorders due to other causes. Treatment of mitochondrial GI disease includes noninvasive or invasive measures. Therapy is usually symptomatic. Only for myo-neuro-gastro-intestinal encephalopathy is a causal therapy with autologous stem-cell transplantation available. It is concluded that GI manifestations of MIDs are more widespread than so far anticipated and that they must be recognized as early as possible to initiate appropriate diagnostic work-up and avoid any mitochondrion-toxic treatment.

Evaluation of the effect of curcumin capsules on glyburide therapy in patients with type-2 diabetes mellitus

This study aimed to assess the possible beneficial effects of curcumin capsules as lipid-lowering effects and as a permeability glycoprotein (P-gp) inhibitor on the pharmacokinetics and pharmacodynamics of glyburide and as a P-gp substrate with glyburide in patients with type-2 diabetes mellitus. Open-label, randomized control trial was carried out for 11 days on eight type-2 diabetic patients on glyburide therapy. On the first day of the study, following the administration of 5 mg of glyburide, blood samples were collected from the patients at various time intervals ranging from 0.5 to 24 h. Blood sampling was repeated on the 11th day of the study, after treating the patients with curcumin for ten consecutive days. Glyburide concentrations changed at the second hour, Cmax was unchanged, the glucose levels were decreased, Area Under first Movement Curre (AUMC) was increased, and no patient has experienced the hypoglycaemia. The low-density lipoprotein, very-low-density lipoprotein and triglycerides were decreased significantly, and the high-density lipoprotein content increased. The co-administration of curcumin capsules with glyburide may be beneficial to the patients in better glycaemic control. The lipid lowering and antidiabetic properties of the curcumin show as a potential future drug molecule.

Current status of multichannel electrogastrography and examples of its use

Electrogastrography (EGG) is a non-invasive diagnostic motility for recording gastric myoelectrical activity. Gastric myoelectrical activity was first recorded in 1922. Advances in recording equipment enabled widespread use of cutaneous EGG after 1985. Later, introduction of multichannel EGG (M-EGG) enabled measurement of electrical activity transmission. At present, M-EGG findings are used as objective indicators of gastric motility disorders caused by various diseases. EGG measures two categories of gastric electrical activity: electrical response activity, or spike potentials; and electrical control activity, or slow waves. The appearance of abnormal rhythmic electrical activity is indicative of abnormalities in gastric motility. The normal frequency range of gastric electrical activity (normogastria) is around 3 cycles per min. Multiple EGG parameters assist in the assessment of gastric myoelectrical activity, and significant correlations between EGG and other gastric motility tests have been demonstrated in many studies. In Japan, however, EGG remains in the exploratory stage, and its clinical use is limited. There are large variations in procedures and systems used in previous studies, thus there is a need for standardization of EGG procedures and technical terminology. Here, we outline the current status of EGG and report the M-EGG procedures used in our department in addition to our M-EGG findings.

The abstract of this manuscript was presented during an educational seminar titled "Current status of gastrointestinal motility tests and keys for immediate implementation" at the 54th Annual Meeting of the Japan Society of Smooth Muscle Research

Variable abnormal physiological motility in the proximal upper gastrointestinal tract in gastroparesis

BACKGROUND

Traditional testing for gastroparesis with gastric emptying scintigraphy (GES) likely misses a subset of patients because of the heterogeneous nature of the disease. The primary aim of this study is to determine the prevalence of simultaneously measured transit and pressure abnormalities in patients with gastroparesis. The secondary aim is to assess diagnostic gain realized by measuring antroduodenal pressure and gastric transit with wireless motility capsule (WMC) compared to gastric transit measured by GES. Identification of abnormalities beyond gastric transit delay in gastroparesis may yield novel targets for pharmacological therapies.

METHODS

Forty-three subjects with symptoms of gastroparesis and previous abnormal GES within 2 years were enrolled in the study. Subjects underwent simultaneous GES and WMC to assess gastric transit. Gastric and small bowel pressure profiles were measured by WMC to determine the contribution of pressure to diagnostic gain realized with WMC.

KEY RESULTS

Fifty-one percent of subjects had abnormal GES while 70% of subjects had either abnormal gastric emptying time (GET) or antroduodenal pressure. Gastric emptying time was abnormal in 60% of subjects while gastric or small bowel pressure was abnormal in 47% of subjects. The overall diagnostic gain of WMC compared to GES was 19% (P = 0.04). Seven percent of subjects had abnormal small bowel pressure profiles when both GES and GET were normal.

CONCLUSIONS & INFERENCES

(i) Gastroparesis is a heterogeneous disorder and testing only solid food emptying by scintigraphy may miss a significant amount of pathology. (ii) Measuring complementary aspects of gastric and small bowel function simultaneously results in greater detection of physiologic abnormalities that may underlie patient symptoms.

Electrogastrography abnormalities appear early in children with diabetes type 1

OBJECTIVE

The objective of the study was to evaluate gastric myoelectrical activity in young patients with diabetes and to correlate it with their metabolic control [fasting blood glucose, glycosylated haemoglobin, and fructosamine] and BMI during a 3 years follow-up.

METHODS

Surface electrogastrography (EGG) was performed on 49 children with diabetes aged 10.3±4.4 (mean±SD) years and 17 age-matched healthy controls after fasting glucose, glycosylated haemoglobin, and fructosamine were measured. EGG parameters [percentage of bradygastria, 3 cycles per minute, tachygastria, dominant frequency instability coefficient, and power ratio] were analysed and compared with blood analysis.

RESULTS

Patients with diabetes exhibited an increase in preprandial bradygastria 7.9±8.8 cpm (mean±SD) compared with controls 2.1±1.0 (P=0.011), with an associated decrease in preprandial normogastria (72.2±14.5 vs. 82.7±14.7; P=0.013). Normogastric power ratio (postprandial/ preprandial power) was significantly increased in the children with diabetes compared with controls (mean: 6.67 vs. 3.14, P=0.034). A longer duration of diabetes was associated with an increased risk of EGG abnormalities (P=0.036). Marked hyperglycaemia at the time of study was associated with postprandial bradygastria (P=0.01) and power ratio bradygastria (P=0.042). Changes in glycosylated haemoglobin, fructosamine and BMI did not affect EGG parameters.

CONCLUSIONS

EGG abnormalities, presented early in a high proportion of diabetic children, are related to the acute hyperglycaemia. These abnormalities are not consistently present in the follow-up studies and not related to the glycosylated haemoglobin and fructosamine. Diabetic autonomic neuropathy is therefore an unlikely pathogenic factor for EGG abnormalities in children with diabetes.

Gastroparesis: pathogenesis, diagnosis and management

Gastroparesis is a prevalent condition that produces symptoms of delayed gastric emptying in the absence of physical blockage. The most common etiologies of gastroparesis are idiopathic, diabetic, and postsurgical disease, although some cases stem from autoimmune, paraneoplastic, neurologic or other conditions. Histologic examination of gastric tissues from patients with severe gastroparesis reveals heterogeneous and inconsistent defects in the morphology of enteric neurons, smooth muscle and interstitial cells of Cajal, and increased levels of inflammatory cells. Diagnosis is most commonly made by gastric emptying scintigraphy; however, wireless motility capsules and nonradioactive isotope breath tests have also been validated. A range of treatments have been used for gastroparesis including dietary modifications and nutritional supplements, gastric motor stimulatory or antiemetic medications, endoscopic or surgical procedures, and psychological interventions. Most treatments have not been subjected to controlled testing in patients with gastroparesis. The natural history of this condition is poorly understood. Active ongoing research is providing important insights into the pathogenesis, diagnosis, treatment and outcomes of this disease.

Do HbA1C Levels Correlate With Delayed Gastric Emptying in Diabetic Patients?

Background/Aims

Gastroparesis is characterized by delayed gastric emptying without obstruction. Diabetes is frequently associated with poor glycemic control and delayed gastric emptying. Gastric emptying scintigraphy (GES) is the standard for measuring gastric emptying. Serum hemoglobin A1C (HbA1C) measures prolonged glycemic control with normal as < 7% glycated. To date, no correlation of serum HbA1C level with gastric emptying, demonstrated by GES, in diabetics has been performed. The aim of the present investigation is to determine if a relationship exists between serum HbA1C levels and gastric emptying, assessed by GES, in diabetics.

Methods

All diabetics, having both GES and serum HbA1C level within 3 months from July 1, 2003 - June 30, 2008 were eligible for study. Demographic data collected included gender, age and ethnicity. Abnormal gastric emptying was defined as T½ > 120 minutes and serum HbA1C as percent glycated.

Results

Nuclear Medicine GES database review revealed 431 examinations performed during the study interval. A total of 181 were not eligible due to the following: 29 duplicates, 22 diabetes not documented and 130 without HbA1C levels, resulting a study group of 250 cases. No significant correlation was observed between gastric emptying time, HbA1C or age. Among patients with HbA1C ≥ 7%, HbA1C was inversely related to age with a coefficient of correlation of r = -0.175 (p = 0.038).

Conclusions

There is no correlation observed between gastric emptying time, using GES, and serum HbA1C levels. In diabetics, serum HbA1C is not as important as daily glycemic control regarding gastric emptying.

Diabetic gastroparesis: diagnosis and management

Gastric emptying is frequently abnormal in patients with long-standing type 1 and type 2 diabetes mellitus. Symptoms commonly associated with disordered gastric emptying include nausea, vomiting, bloating and epigastric pain, while patients are also at risk of malnutrition, weight loss, impaired drug absorption, disordered glycaemic control and poor quality of life. Although often attributed to the presence of irreversible autonomic neuropathy, acute hyperglycaemia represents a potentially reversible cause of gastric dysfunction in diabetes. Scintigraphy represents the gold standard for measuring gastric emptying. The management of diabetic gastroparesis is less than optimal, partly because the pathogenesis has not been clearly defined. Treatment approaches include dietary modification and optimization of glycaemia, and the use of prokinetic drugs, while novel therapies such as gastric electrical stimulation are the subject of ongoing investigation.

Serum high-molecular weight adiponectin is related to early postprandial glycemic increases and gastric emptying in patients with type 2 diabetes mellitus

BACKGROUND

Postprandial hyperglycemia and hyperlipidemia are frequently associated with type 2 diabetes mellitus. The aim of the present study is to investigate the clinical determinants of postprandial glycemia and lipemia, especially serum high-molecular weight adiponectin.

METHODS

Twenty-seven diabetic patients treated with diet alone and 13 healthy volunteers took liquid test meal containing 53 g carbohydrate and 47 g lipid, dosed with nonradioactive isotope (13)C-acetate. Venous blood and breath samples were obtained for 180 min after the meal. Gastric emptying was evaluated by peak excretion time of (13)CO(2) in the breath samples. Delayed gastric emptying was defined as peak excretion time > 2.5 h (mean + 2 SD in the healthy volunteers).

RESULTS

Diabetic patients showed delayed insulin secretion, postprandial hyperglycemia and hyperlipidemia compared with control. Postprandial glycemic increases significantly correlated with enhanced gastric emptying. Serum high-molecular weight adiponectin correlated with postprandial glycemic increases at 30 and 60 min after meal (r = 0.42, p < 0.05; r = 0.37, p < 0.05, respectively). Serum high-molecular weight adiponectin also correlated with gastric emptying (versus peak excretion time r = - 0.58, p < 0.05). In addition, diabetic patients with delayed gastric emptying showed the suppressed postprandial glycemia with lower serum high-molecular weight adiponectin than those with normal gastric emptying. On the other hand, postprandial increases in serum triglyceride were not related to serum high-molecular weight adiponectin or gastric emptying, but significantly related to liver function test (serum transaminases) and body mass index.

CONCLUSIONS

Early postprandial glycemic increases were related to elevated serum high-molecular weight adiponectin, which might be associated with enhanced gastric emptying.

Management of gastroparesis

Gastroparesis presents with nausea, vomiting, early satiety and abdominal discomfort, as well as a range of nongastrointestinal manifestations in association with delays in gastric emptying. The disorder may be a consequence of systemic illnesses, such as diabetes mellitus, occur as a complication of gastroesophageal surgery or develop in an idiopathic fashion and may mimic other disorders with normal gastric emptying. Some cases of idiopathic gastroparesis present after a viral infection. Management relies primarily on therapies that accelerate gastric emptying or reduce vomiting, although endoscopic or surgical options are available for refractory cases. Current research is focusing on the cellular and molecular mechanisms underlying development of delayed gastric emptying, as well as factors unrelated to motor dysfunction that may elicit some symptoms. Future pharmaceuticals will target the contractile and nonmotor defects via novel pathways. Novel electrical stimulation techniques will be employed either alone or in combination with medications.

Gastroparesis: symptoms, evaluation, and treatment

Gastroparesis presents with gastrointestinal symptoms and nongastrointestinal manifestations in association with objective delays in gastric emptying. The condition may complicate several systemic disorders or may be idiopathic in nature. The diagnosis is made by directed evaluation to exclude organic diseases, which can mimic the clinical presentation of gastroparesis coupled with quantification of gastric emptying. Current therapies rely on dietary modifications, medications to stimulate gastric evacuation, and agents to reduce vomiting. Endoscopic and surgical options are increasingly used for cases refractory to medication treatment.

Pathophysiology and management of diabetic gastropathy: a guide for endocrinologists

Delayed gastric emptying is frequently observed in patients with long-standing type 1 and type 2 diabetes mellitus, and potentially impacts on upper gastrointestinal symptoms, glycaemic control, nutrition and oral drug absorption. The pathogenesis remains unclear and management strategies are currently suboptimal. Therapeutic strategies focus on accelerating gastric emptying, controlling symptoms and improving glycaemic control. The potential adverse effects of hyperglycaemia on gastric emptying and upper gut symptoms indicate the importance of normalising blood glucose if possible. Nutritional and psychological supports are also important, but often neglected. A number of recent pharmacological and non-pharmacological therapies show promise, including gastric electrical stimulation. As with all chronic illnesses, a multidisciplinary approach to management is recommended, but there are few data regarding long-term outcomes.