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Yang DY, Camilleri M. The goals for successful development of treatment in gastroparesis. Neurogastroenterol Motil 2024:e14849. [PMID: 38884392 DOI: 10.1111/nmo.14849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/10/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Gastroparesis is a motility disorder of the stomach characterized by cardinal symptoms and delayed gastric emptying of solid food in the absence of mechanical obstruction. There is significant unmet need in its management, and essentially there are no medications approved for its treatment over four decades. PURPOSE The objectives of this review are to develop an understanding of the goals of treatment, the evidence-based criteria for treatment success based on the current scientific understanding of gastroparesis as well as patient response outcomes, and to propose evidence-based principles for the successful development of treatments for gastroparesis. Specifically, we discuss the pathophysiologic targets in gastroparesis, eligibility criteria for clinical trial participation based on validated gastric emptying studies, and the patient response outcome measures that have been validated to appraise effects of treatment on clinically relevant outcomes. These considerations lead to recommendations regarding eligibility, design, and duration of proof-of-efficacy studies, and to endorsing the American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index Daily Diary as a validated patient response outcome and to justification of the shortening of proof-of-efficacy, placebo-controlled clinical trials to 4 weeks treatment duration after a baseline period. We believe that such approaches will increase the likelihood of successful assessment of efficacy of novel approaches to treating patients with gastroparesis.
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Affiliation(s)
- David Yi Yang
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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2
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Wang XJ, O'Connor M, Peck T, Johnston G, Prichard DO. Extensive scintigraphic gastric motor function testing with concurrent symptom recording predicts prospectively measured daily dyspeptic symptoms. Neurogastroenterol Motil 2024:e14819. [PMID: 38816956 DOI: 10.1111/nmo.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 03/14/2024] [Accepted: 05/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Absent "organic" disease, dyspeptic symptoms may arise from abnormal gastric sensation, accommodation, motility or emptying (GE). Extensive gastric sensorimotor evaluation is rarely undertaken because testing is prolonged, invasive, poorly tolerated or unavailable. AIMS To investigate whether gastric antral motor function, evaluated with scintigraphy, predicts GE. To explore whether motor testing with symptom recording predicts day-to-day symptoms in patients with dyspepsia. METHODS GE was determined using a scintigraphic solid-meal protocol (296 kcal, 35% fat). Antral motility was estimated from 10 min of scintigraphic time-activity curves acquired 40 min after meal consumption. An antral motility index (MI) was derived from contraction amplitude and frequency. Intra-gastric distribution of the meal on scintograms at 1 h (IGD1) was determined. Meal-induced symptoms were evaluated by questionnaire. Patients completed the Gastroparesis Cardinal Symptom Index Daily Diary (GCSI-DD) for 14 days. RESULTS Twelve healthy participants and 23 prospectively recruited patients completed the study. Nine patients had delayed, and 2 had rapid, GE. In univariate analysis MI explained 42% of GE half-time. In multivariate analysis MI and GE half-time explained 25% of the variance in meal-induced symptoms. While scintigraphic evaluation of gastric motor function with symptom recording explained 80% of the variance in the GCSI-DD, meal-induced symptoms were the only significant predictor. However, among patients with delayed GE, MI, GE half-time, IGD1, and meal-induced symptoms all significantly predicted GCSI-DD. CONCLUSIONS Antral motility predicts GE. In exploratory analyses, only meal-induced symptoms predicted daily symptoms among patients with dyspepsia. However, motor function also predicted symptoms in patients with delayed GE.
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Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael O'Connor
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Taylor Peck
- Division of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Geoffrey Johnston
- Division of Nuclear Medicine, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, St James' Hospital, Dublin, Ireland
- University of Dublin, Trinity College, Dublin, Ireland
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3
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Saleem S, Tarar ZI, Aziz M, Alsamman MA, Tansel A, Abell TL. Cannabis Use in Patients with Gastroparesis. Cannabis Cannabinoid Res 2023; 8:1100-1105. [PMID: 36067326 DOI: 10.1089/can.2022.0189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aim: The primary aim was to determine the prevalence of cannabis use among patients hospitalized for gastroparesis. The secondary aim was to identify independent variables associated with cannabis use compared with noncannabis-related gastroparesis hospitalization. Methods: We use the nationwide inpatient sample database from January 2012 to December 2014. The patients included in this study were the ones with primary diagnosis of gastroparesis and cannabis use. The analysis was performed using the Statistical Package for the Social Sciences 27 (SPSS) and a multivariable regression was conducted to identify independent variables. Results: We found 50,170 patients with a primary diagnosis of gastroparesis. The prevalence of cannabis use among patients hospitalized for gastroparesis was 4.2%. Multivariate regression analysis was performed, adjusting for confounders. The variables found to increase the odds of cannabis use in gastroparesis populations independently were age interval of 18-35 and 36-50 years, male, Black and Asian, median household income 1-25th percentile, Medicaid insurance, no charge hospitalization, and smoking. Cannabis use was associated with lower odds of vomiting. Conclusion: Patients who used cannabis were younger and of African American, Asian, or Pacific Islander descent. They had Medicaid insurance and a lower median household income.
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Affiliation(s)
- Saad Saleem
- Department of Internal Medicine, Sunrise Hospital and Medical Center, Las Vegas, Nevada, USA
| | - Zahid Ijaz Tarar
- Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Muhammad Aziz
- Department of Gastroenterology, Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Mohd Amer Alsamman
- Department of Gastroenterology, Georgetown University, Washington, District of Columbia, USA
| | - Aylin Tansel
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thomas L Abell
- Department of Gastroenterology, University of Louisville, Louisville, Kentucky, USA
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4
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Li M, Gao N, Wang S, Guo Y, Liu Z. A global bibliometric and visualized analysis of the status and trends of gastroparesis research. Eur J Med Res 2023; 28:543. [PMID: 38017518 PMCID: PMC10683151 DOI: 10.1186/s40001-023-01537-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Gastroparesis has a substantial impact on the quality of life but has limited treatment options, which makes it a public health concern. No bibliometric studies on gastroparesis have been published thus far. Thus, this article aims to summarize and analyze research hotspots to provide a reference for clinical researchers. MATERIALS AND METHODS Gastroparesis-related research articles were searched in the Web of Science Core Collection (WOSCC), and relevant information was extracted after screening. A total of 1033 documents were analyzed with the bibliometric method using Microsoft Excel, Citespace, and VOSviewer. RESULTS Overall, our search retrieved 1033 papers contributed by 966 research institutions from 53 countries. Since 1980, publications in this field have increased rapidly. United States (n = 645) and Temple University (n = 122) were the most productive country and institution, respectively. Parkman, with 96 publications, was the most prominent author. CONCLUSIONS Research hotspots in gastroparesis can be summarized into four domains: innovation in diagnostic modalities, change of oral therapeutic agents, choice of surgical interventions, and pathological mechanisms. Future research on gastroparesis should focus on the quality of life of patients, diagnostic techniques, pyloromyotomy, and transpyloric stent placement.
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Affiliation(s)
- Meng Li
- Department of Gastroenterology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China
| | - Ning Gao
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China
| | - Shaoli Wang
- Department of Gastroenterology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China
| | - Yufeng Guo
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China.
| | - Zhen Liu
- Department of Gastroenterology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China.
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Karunaratne T, Yan Y, Eubanks A, Inman B, Rao S, Sharma A. Thoracic Spinal Nerve Neuromodulation Therapy for Diabetic Gastroparesis: A Proof-of-Concept Study. Clin Gastroenterol Hepatol 2023; 21:2958-2959.e3. [PMID: 36152902 PMCID: PMC10030375 DOI: 10.1016/j.cgh.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/29/2022] [Accepted: 09/12/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Tennekoon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Yun Yan
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Audrey Eubanks
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Brooke Inman
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Satish Rao
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Amol Sharma
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia.
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Ichkhanian Y, Al-Haddad MA, Jacobs CC, Schlachterman A, Yang J, Canakis A, Kim R, Guerson-Gil A, D'Souza LS, Alsheik E, Ginnebaugh BD, Khashab MA, Zuchelli T, McFarlin K, Piraka C. Gastric peroral endoscopic myotomy for management of refractory gastroparesis in patients with gastric neurostimulator devices: a multicenter retrospective case control study. Gastrointest Endosc 2023; 98:559-566.e1. [PMID: 37121364 DOI: 10.1016/j.gie.2023.04.2079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/28/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND AIMS Gastric neurostimulation (GNS) and gastric peroral myotomy (G-POEM), therapies for refractory gastroparesis, are associated with suboptimal outcomes. We studied the role of G-POEM as a salvage therapy in patients with refractory symptoms after GNS implantation. METHODS This was a multicenter, retrospective, matched case-control study. Consecutive patients with a GNS device and who underwent G-POEM as a salvage therapy for clinical failure (cases) and patients without GNS implantation and who underwent G-POEM for refractory gastroparesis (control) between October 2018 and August 2021 were included. The primary outcome was clinical success after G-POEM. RESULTS A total of 123 patients (mean age 45.7 ± 14.7 years; 88 female subjects [72%]) underwent G-POEM therapy during the study: 41 cases and 82 controls. Clinical success was achieved in 66% in the case group and 65% in the control group (P = .311), during a median total clinical follow-up time of 11.8 (interquartile range, 2.4-6.3) months. In the case group, the mean Gastroparesis Cardinal Symptom Index score decreased from 2.8 ± 1.8 to 1.5 ± 1.9 (P = .024), and gastric retention at 4 hours improved from 45% ± 25.8% to 16.6% ± 13.1% (P = .06). The mean delta improvement in the subscales of nausea/vomiting (1.3 ± .6 vs .9 ± 1.1, P = .044) and bloating (1.6 ± 1.3 vs 1.2 ± 1.4, P = .041) were significantly higher in cases than in controls. CONCLUSIONS Among patients with refractory symptoms after GNS, G-POEM can be a reasonable salvage therapy to provide further symptomatic relief with evidence of a potential additive effect of both G-POEM and GNS.
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Affiliation(s)
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Chelsea C Jacobs
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Raymond Kim
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Arcelia Guerson-Gil
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Lionel S D'Souza
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | | | | | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA (10)Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | - Kellie McFarlin
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
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Zahid SA, Tated R, Mathew M, Rajkumar D, Karnik SB, Pramod Roy A, Jacob FP, Baskara Salian R, Razzaq W, Shivakumar D, Khawaja UA. Diabetic Gastroparesis and its Emerging Therapeutic Options: A Narrative Review of the Literature. Cureus 2023; 15:e44870. [PMID: 37814758 PMCID: PMC10560130 DOI: 10.7759/cureus.44870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/06/2023] [Indexed: 10/11/2023] Open
Abstract
Diabetic gastroparesis (DG) is one of the many complications of diabetes mellitus (DM). Even though this condition surfaces years after uncontrolled disease, it affects the quality of life in several ways and causes significant morbidity. Common symptoms experienced by the patients include postprandial nausea, vomiting, abdominal fullness, and pain. Strict glycemic control is essential to evade the effects of DG. The purpose of this review article is to briefly study the pathophysiology, clinical features, diagnostic modalities, and the effects of DG on different aspects of life. Furthermore, it also focuses on the emerging treatment modalities for DG. Tradipitant and relamorelin are two such treatment options that are gaining noteworthy recognition and are discussed in detail in this review article. As observed through various clinical trials, these drugs help alleviate symptoms like nausea, vomiting, abdominal pain, and bloating in patients suffering from DG, thereby targeting the most common and bothersome symptoms of the disease. This leads to an improvement in the quality of life, making it a reliable treatment option for this disease. But while pharmacological intervention is vital, psychological support and lifestyle changes are equally important and are the reason why a multidisciplinary approach is required for the treatment of DG.
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Affiliation(s)
- Shiza A Zahid
- Department of Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Ritu Tated
- Department of Internal Medicine, Mahatma Gandhi Mission Institute of Medical Sciences, Navi Mumbai, IND
| | - Midhun Mathew
- Department of Internal Medicine, Pennsylvania Hospital, Philadelphia, USA
| | - Daniel Rajkumar
- Department of Internal Medicine, Hospital Alor Gajah, Alor Gajah, MYS
| | - Siddhant B Karnik
- Department of Internal Medicine, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, IND
| | | | - Fredy P Jacob
- Department of Internal Medicine, Jonelta Foundation School of Medicine, University of Perpetual Help System DALTA, Las Piñas, PHL
| | | | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Divya Shivakumar
- Department of Internal Medicine, Kamineni Academy of Medical Sciences and Research Center, Hyderabad, IND
| | - Uzzam Ahmed Khawaja
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
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Tanner SE, Kurin M, Shahsavari D, Malik Z, Parkman HP. Trends in Gastroparesis Management: A United States Population-based Study From 2010 to 2020. J Clin Gastroenterol 2023; 57:789-797. [PMID: 36227007 DOI: 10.1097/mcg.0000000000001766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 08/23/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND There is little consensus on the medical management of gastroparesis, a disorder characterized by delayed gastric emptying with symptoms of early satiety, nausea, vomiting, and upper abdominal pain. GOALS We utilized population-level data to: (1) describe the prevalence of different pharmacological and nonpharmacological therapies in patients with gastroparesis; and (2) trend the prevalence of these therapies from 2010 to 2020. STUDY More than 59 million unique medical records across 26 US-based major health care systems were surveyed using the Explorys platform to identify a cohort of adults with gastroparesis who completed both a gastric emptying study and upper endoscopy or upper gastrointestinal tract imaging. Prevalence of antiemetic, prokinetic, neuromodulator prescriptions, and surgical therapies for gastroparesis were searched within this cohort and trended annually from 2010 to 2020. RESULTS Antiemetics (72% of patients), prokinetics (47%), and neuromodulators (75% of patients, 44% of patients without a concomitant psychiatric or diabetic peripheral neuropathy diagnosis) were all commonly used in the treatment of patients with gastroparesis. From 2010 to 2020, there was an increase in the prevalence of antiemetic and neuromodulator prescriptions (36.4% to 57.6%, P <0.001 and 47.0% to 66.9%, P <0.001, respectively), whereas the prevalence of prokinetics remained relatively constant (31.8% to 31.6%, P =0.52). Procedural and surgical treatments were used in 5% of gastroparesis patients. CONCLUSIONS Treatments for gastroparesis have changed over the last decade: antiemetic and neuromodulator use has increased whereas prokinetic use has remained constant. This practice pattern may reflect the growing number and availability of antiemetics and neuromodulators and the small number and known side effects of prokinetics.
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Affiliation(s)
| | - Michael Kurin
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Dariush Shahsavari
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Mandarino FV, Testoni SGG, Barchi A, Azzolini F, Sinagra E, Pepe G, Chiti A, Danese S. Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment. Life (Basel) 2023; 13:1743. [PMID: 37629600 PMCID: PMC10455809 DOI: 10.3390/life13081743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Sabrina Gloria Giulia Testoni
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy;
| | - Gino Pepe
- Department of Nuclear Medicine, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.P.); (A.C.)
| | - Arturo Chiti
- Department of Nuclear Medicine, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.P.); (A.C.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
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10
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Parkman HP, Yates KP, Sarosiek I, Bulat RS, Abell TL, Koch KL, Kuo B, Grover M, Farrugia G, Silver P, Abdullah A, Maurer AH, Malik Z, Miriel LA, Tonascia J, Hamilton F, Pasricha PJ, McCallum RW. Buspirone for early satiety and symptoms of gastroparesis: A multi-centre, randomised, placebo-controlled, double-masked trial (BESST). Aliment Pharmacol Ther 2023; 57:1272-1289. [PMID: 37052334 PMCID: PMC10202558 DOI: 10.1111/apt.17479] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/18/2023] [Accepted: 03/10/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Patients with gastroparesis and related disorders have symptoms including early satiety, postprandial fullness and bloating. Buspirone, a 5-HT1 receptor agonist, may improve fundic accommodation. AIM To determine if buspirone treatment improves early satiety and postprandial fullness in patients with symptoms of gastroparesis. METHODS This 4-week multi-centre clinical trial randomised patients with symptoms of gastroparesis and moderate-to-severe symptoms of fullness (Gastroparesis Cardinal Symptom Index [GCSI] early satiety/postprandial fullness subscore [ES/PPF]) to buspirone (10 mg orally) or placebo three times per day. The primary outcome was a change in the ES/PPF from baseline to 4 weeks. The primary analysis was per protocol intention-to-treat ANCOVA of between-group baseline vs. 4-week differences (DoD) in ES/PPF adjusted for baseline ES/PPF. Results are reported using both nominal and Bonferroni (BF) p values. RESULTS AND CONCLUSIONS Ninety-six patients (47 buspirone, 49 placeboes; 92% female, 50% delayed gastric emptying, 39% diabetic) were enrolled. There was no between-groups difference in the 4-week ES/PPF primary outcome: -1.16 ± 1.25 (SD) on buspirone vs -1.03 ± 1.29 (SD) on placebo (mean DoD: -0.11 [95% CI: -0.68, 0.45]; p = 0.69). Buspirone performed better than placebo in patients with severe-to-very severe bloating at baseline compared to patients with none to moderate: (ES/PPF DoD = -0.65 vs. 1.58, pTX*GROUP = 0.003; pBF = 0.07). Among individual GCSI symptoms, only bloating appeared to improve with buspirone vs. placebo. CONCLUSIONS Patients with moderate-to-severe early satiety/postprandial fullness and other symptoms of gastroparesis did not benefit from buspirone treatment to improve the ES/PPF primary outcome compared with placebo. There was a suggestion of the benefit of buspirone in patients with more severe bloating. TRIAL REGISTRATION ClinicalTrials.gov NCT0358714285.
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Affiliation(s)
| | | | - Irene Sarosiek
- Texas Tech University Health Sciences Center, El Paso, TX
| | | | | | | | | | | | | | | | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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11
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El Halabi M, Parkman HP. 2023 update on the clinical management of gastroparesis. Expert Rev Gastroenterol Hepatol 2023; 17:431-441. [PMID: 36970885 DOI: 10.1080/17474124.2023.2196404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Gastroparesis is characterized by symptoms suggesting gastric retention of food and objective evidence of delayed gastric emptying in the absence of a mechanical obstruction. Nausea, vomiting, early satiety, and postprandial fullness are the classic symptoms of gastroparesis. Gastroparesis is increasingly encountered by physicians. There are several recognized etiologies of gastroparesis, including diabetic, post-surgical, medication-induced, post-viral, and idiopathic. AREAS COVERED A comprehensive literature review was conducted to identify studies discussing gastroparesis management. Dietary modifications, medication adjustments, glucose control, antiemetic agents, and prokinetic agents are all part of gastroparesis management. In this manuscript, we detail treatments evolving for gastroparesis, including nutritional, pharmaceutical, device, and recent advanced endoscopic and surgical therapies. This manuscript concludes with a speculative viewpoint on how the field will evolve in 5 years' time. EXPERT OPINION Identification of the dominant symptoms (fullness, nausea, abdominal pain, and heartburn) helps to direct management efforts of the patients. Treatments for refractory (treatment resistant) symptoms may include gastric electric stimulation and intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy. Understanding the pathophysiology of gastroparesis, relating pathophysiologic abnormalities to specific symptoms, new efficacious pharmacotherapies, and better understanding of the clinical predictors of response of therapies, are priorities for future research in the field of gastroparesis.
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Affiliation(s)
- Maan El Halabi
- GI Motility Fellow, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Professor of Medicine, Director of GI Motility Laboratory, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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12
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Schwalbe K, Finelli C, Moon S, Niehaus H, Kondajji A, Tu C, Fathalizadeh A, Kroh M, Allemang M. Endoscopic findings do not predict per-oral pyloromyotomy (POP) response. Surg Endosc 2023; 37:1384-1391. [PMID: 35608698 DOI: 10.1007/s00464-022-09321-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Gastroparesis is a life-altering diagnosis caused by the stomach's inability to function in the absence of a mechanical obstruction. The primary causes are idiopathic, diabetic, and postoperative. Our first-line treatment for medical refractory gastroparesis is the endoscopic per-oral pyloromyotomy (POP) procedure. Predicting clinical response cost effectively remains elusive. METHODS All patients who underwent a POP procedure at our institution by a single surgical endoscopist from January 1, 2019 to June 30, 2020 were retrospectively reviewed. All endoscopic data were prospectively collected. The patients were followed by a survey including the Gastroparesis Cardinal Symptom Index (GCSI) and other relevant postoperative measures. The primary endpoint was clinical response defined as ≥ 1.0 decrease in the GCSI from preoperative to the time of survey. Secondary outcome was normalization of the gastric emptying study (GES). RESULTS Our patient population is 85% female and has an average age of 44.8 years. The diagnosis of gastroparesis is 71% iatrogenic, 19% postoperative, and 10% diabetic. On endoscopy, 30% had bile in the stomach and 65% had any degree of pylorospasm. The primary outcome measure of clinical response was 39% at an average of 697 ± 151 days post-POP, but 66% of patients attested to an improvement in their symptoms. Of 68 postoperative gastric emptying studies 50% normalized at an average of 145 ± 98 days. Following univariate and multivariate analyses of preoperative data and endoscopic findings, there were no significant predictors of clinical response. A preoperative GCSI ≥ 2.6 trends toward significance (OR 6.87, p = 0.058). CONCLUSION Endoscopic findings at the time of POP do not correlate with clinical response. The GCSI model currently used to measure clinical response may not accurately capture the full clinical picture. The long-term durability of endoscopic myotomy to treat medical refractory gastroparesis needs to be studied further to improve patient selection.
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Affiliation(s)
- Kathryn Schwalbe
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA.
| | - Caitlin Finelli
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Soon Moon
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Hannah Niehaus
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Abhiram Kondajji
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Matthew Kroh
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Allemang
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
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13
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Sato H, Grover M. Gastroparesis and Functional Dyspepsia: Spectrum of Gastroduodenal Neuromuscular Disorders or Unique Entities? GASTRO HEP ADVANCES 2023; 2:438-448. [PMID: 37151911 PMCID: PMC10162778 DOI: 10.1016/j.gastha.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Gastroparesis is defined by delayed gastric emptying in the absence of mechanical obstruction of the stomach. Patients experience symptoms of nausea, vomiting, abdominal pain, fullness, and early satiety. The recognition of the disorder has progressed due to availability of gastric emptying scintigraphy and advancements made in understanding its pathophysiology and treatment options. The clinical presentation and treatment of gastroparesis overlap with a more commonly recognized disorder of gut-brain interaction, functional dyspepsia. Recent studies have reenergized the discussion whether these two are separate entities or perhaps reflect a spectrum of gastroduodenal neuromuscular disorders. The societal guidelines conflict on the utility of gastric emptying scintigraphy in assessment of patients with upper gastrointestinal symptoms. A better appraisal of similarities and differences between gastroparesis and functional dyspepsia will allow targeted treatment for these disorders. This is particularly important as specific pharmacological and endoscopic treatment options are being developed for gastroparesis which are unlikely to be helpful for functional dyspepsia. This review makes the case for considering these disorders in a spectrum where identification of both would most ideally position us toward providing the optimal clinical care.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Madhusudan Grover
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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14
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Pasricha PJ, Grover M, Yates KP, Abell TL, Koch KL, McCallum RW, Sarosiek I, Bernard CE, Kuo B, Bulat R, Shulman RJ, Chumpitazi BP, Tonascia J, Miriel LA, Wilson LA, Van Natta ML, Mitchell E, Hamilton F, Farrugia G, Parkman HP. Progress in Gastroparesis - A Narrative Review of the Work of the Gastroparesis Clinical Research Consortium. Clin Gastroenterol Hepatol 2022; 20:2684-2695.e3. [PMID: 35688353 PMCID: PMC9691520 DOI: 10.1016/j.cgh.2022.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/15/2022] [Accepted: 05/05/2022] [Indexed: 01/27/2023]
Abstract
The Gastroparesis Clinical Research Consortium is a multicenter coalition created and funded by the National Institutes of Diabetes and Digestive and Kidney Disorders, with a mission to advance understanding of the pathophysiology of gastroparesis and develop an effective treatment for patients with symptomatic gastroparesis. In this review, we summarize the results of the published Gastroparesis Clinical Research Consortium studies as a ready and convenient resource for gastroenterologists and others to provide a clear understanding of the consortium's experience and perspective on gastroparesis and related disorders.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Braden Kuo
- Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Bulat
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Martinek J, Hustak R, Mares J, Vackova Z, Spicak J, Kieslichova E, Buncova M, Pohl D, Amin S, Tack J. Endoscopic pyloromyotomy for the treatment of severe and refractory gastroparesis: a pilot, randomised, sham-controlled trial. Gut 2022; 71:2170-2178. [PMID: 35470243 PMCID: PMC9554080 DOI: 10.1136/gutjnl-2022-326904] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/05/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic pyloromyotomy (G-POEM) is a minimally invasive treatment option with promising uncontrolled outcome results in patients with gastroparesis. DESIGN In this prospective randomised trial, we compared G-POEM with a sham procedure in patients with severe gastroparesis. The primary outcome was the proportion of patients with treatment success (defined as a decrease in the Gastroparesis Cardinal Symptom Index (GCSI) by at least 50%) at 6 months. Patients randomised to the sham group with persistent symptoms were offered cross-over G-POEM. RESULTS The enrolment was stopped after the interim analysis by the Data and Safety Monitoring Board prior to reaching the planned sample of 86 patients. A total of 41 patients (17 diabetic, 13 postsurgical, 11 idiopathic; 46% male) were randomised (21 G-POEM, 20-sham). Treatment success rate was 71% (95% CI 50 to 86) after G-POEM versus 22% (8-47) after sham (p=0.005). Treatment success in patients with diabetic, postsurgical and idiopathic gastroparesis was 89% (95% CI 56 to 98), 50% (18-82) and 67% (30-90) after G-POEM; the corresponding rates in the sham group were 17% (3-57), 29% (7-67) and 20% (3-67).Median gastric retention at 4 hours decreased from 22% (95% CI 17 to 31) to 12% (5-22) after G-POEM and did not change after sham: 26% (18-39) versus 24% (11-35). Twelve patients crossed over to G-POEM with 9 of them (75%) achieving treatment success. CONCLUSION In severe gastroparesis, G-POEM is superior to a sham procedure for improving both symptoms and gastric emptying 6 months after the procedure. These results are not entirely conclusive in patients with idiopathic and postsurgical aetiologies. TRIAL REGISTRATION NUMBER NCT03356067; ClinicalTrials.gov.
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Affiliation(s)
- Jan Martinek
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Praha, Czech Republic
| | - Rastislav Hustak
- Department of Internal Medicine, University Hospital Trnava, Trnava, Slovakia
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Jan Mares
- Department of IT and Biostatistics, Institute of Clinical and Experimental Medicine, Praha, Czech Republic
| | - Zuzana Vackova
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Praha, Czech Republic
| | - Julius Spicak
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Praha, Czech Republic
| | - Eva Kieslichova
- Department of Anesthesiology and Intensive Care, Institute of Clinical and Experimental Medicine, Praha, Czech Republic
| | - Marie Buncova
- Department of Nuclear Medicine, Institute of Clinical and Experimental Medicine, Praha, Czech Republic
| | - Daniel Pohl
- Division of Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Sunil Amin
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jan Tack
- Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
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Baret F, Jacques J, Pioche M, Albouys J, Vitton V, Vanbiervliet G, Debourdeau A, Barthet M, Gonzalez JM. Evaluation of the safety profile of endoscopic pyloromyotomy by G-POEM: a French multicenter study. Therap Adv Gastroenterol 2022; 15:17562848221122472. [PMID: 36213725 PMCID: PMC9536103 DOI: 10.1177/17562848221122472] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastric per oral endoscopic esophageal myotomy (G-POEM) is a promising procedure to treat refractory gastroparesis. The safety profile of G-POEM is an important topic because gastroparesis is a functional pathology, with a procedure whose effectiveness is between 50 and 65% depending on the studies. OBJECTIVES We present this retrospective multicenter study, with the aim of establishing a safety profile, focusing on serious adverse events (AEs). DESIGN This was a multicenter observational cohort study conducted in five French expert centers. METHODS All patients who underwent G-POEM for refractory gastroparesis between 2015 and 2021 were included for analysis. AEs were classified into per endoscopic, early postoperative, and late postoperative, up to 1 month. Their severity was assessed using Dindo-Clavien and American Society for Gastrointestinal Endoscopy classification. The primary objective was to evaluate the rate of G-POEM severe AEs. Secondary objectives were to document other postoperative AEs, and to identify predictive factors. RESULTS In all, 217 patients were included: 81 men and 136 women, mean age 52 ± 17 years. The average procedural time was 44 ± 14 min (12-78). The average hospital stay was 3.7 ± 2.3 days. The AEs rate classified as Clavien-Dindo ⩾3 was 0.4% (one delayed bleeding requiring blood transfusion and endoscopic management). There were no deaths or patients admitted to intensive care unit. The rates of mucosotomy and capnoperitoneum were 3.7 and 1.8%, respectively, without clinical consequences. Most patients (81.5%) did not experience any AE. Three cases of dumping syndrome occurred, quickly managed by dietary measures. CONCLUSION Our study confirms the safety of G-POEM with less than 0.5% of serious AEs, medically managed. This outcome makes this a procedure to have a good benefit-risk ratio.
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Affiliation(s)
| | - Jeremie Jacques
- Service de Gastroentérologie, CHU Dupuytren, Limoges, France
| | - Mathieu Pioche
- Service de Gastroentérologie, CHU Edouard Herriot, Lyon, France
| | - Jeremie Albouys
- Service de Gastroentérologie, CHU Dupuytren, Limoges, France
| | | | | | | | - Marc Barthet
- Service de Gastroentérologie, CHU Nord, Marseille, France
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Ichkhanian Y, Hwang JH, Ofosu A, Li AA, Szvarca D, Draganov PV, Yang D, Alsheik E, Zuchelli T, Piraka C, Mony S, Khashab MA. Role of gastric per-oral endoscopic myotomy (G-POEM) in post-lung transplant patients: a multicenter experience. Endosc Int Open 2022; 10:E832-E839. [PMID: 35692909 PMCID: PMC9187381 DOI: 10.1055/a-1797-9587] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Background and study aims Gastroparesis post-lung transplant (LTx) can lead to increased risk of gastroesophageal reflux (GER) and accelerated graft dysfunction. We aimed to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM), a promising tool in patients with refractory gastroparesis, for managing refractory gastroparesis and GER in post-LTx patients. Patents and methods This was a multicenter retrospective study on post-LTx patients who underwent G-POEM for management of gastroparesis and GER that were refractory to standard medical therapy. The primary outcome was clinical success post-G-POEM. Secondary outcomes included the rate of post-G-POEM objective esophageal pH exam normalization, rate of gastric emptying scintigraphy (GES) normalization, technical success, and adverse events. Results A total of 20 patients (mean age 54.7 ± 14.1 years, Female 50 %) underwent G-POEM at a median time of 13 months (interquartile range 6.5-13.5) post-LTx. All G-POEM procedures were technically successful. Clinical success was achieved in 17 (85 %) patients during a median follow-up time of 8.9 (IQR: 3-17) months post-G-POEM. Overall GCSI and two of its subscales (bloating and postprandial fullness/early satiety) improved significantly following G-POEM. Two patients (10 %) developed post-procedural AEs (delayed bleeding 1, pyloric stenosis 1, both moderate in severity). Post-G-POEM GES improvement was achieved in 12 of 16 patients (75 %). All 20 patients were on proton pump inhibitors pre-G-POEM, as opposed to five post-G-POEM. Post-G-POEM PH study normalization was noted in nine of 10 patients (90 %) who underwent both pre- and post-G-poem pH testing. Conclusions G-POEM is a promising noninvasive therapeutic tool for management of refractory gastroparesis and GER post-LTx.
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Affiliation(s)
- Yervant Ichkhanian
- Henry Ford Health System, Department of Internal Medicine, Detroit, Michigan, United States
| | - Joo Ha Hwang
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Andrew Ofosu
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Andrew A Li
- Divisions of Gastroenterology and Hepatology, Stanford University, School of Medicine, Stanford, California, United States
| | - Daniel Szvarca
- Johns Hopkins Hospital, Department of Internal Medicine, Baltimore, Maryland, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Eva Alsheik
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Tobias Zuchelli
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Cyrus Piraka
- Henry Ford Health System, Division of Gastroenterology and Hepatology, Michigan, United States
| | - Shruti Mony
- Johns Hopkins Hospital, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Johns Hopkins Hospital, Division of Gastroenterology and Hepatology, Baltimore, Maryland, United States
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18
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Lee AA, Rao K, Parkman HP, McCallum RW, Sarosiek I, Nguyen LA, Wo JM, Schulman MI, Moshiree B, Rao S, Kuo B, Hasler WL. Baseline Predictors of Longitudinal Changes in Symptom Severity and Quality of Life in Patients With Suspected Gastroparesis. Clin Gastroenterol Hepatol 2022; 20:e407-e428. [PMID: 32971231 PMCID: PMC8719906 DOI: 10.1016/j.cgh.2020.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/12/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Whether gastric emptying tests predict longitudinal outcomes in patients with symptoms of gastroparesis is unclear. We aimed to determine whether baseline gastric emptying tests and gut motility parameters could impact longitudinal symptom(s) and quality of life (QOL) in a prospective, observational cohort study of patients with symptoms of gastroparesis. METHODS One hundred fifty patients with gastroparesis symptoms underwent simultaneous scintigraphy (GES) and wireless motility capsule (WMC) measurement of gastric emptying and other motility parameters. Patient Assessment of Upper Gastrointestinal Symptoms and Quality of Life were administered at baseline, and 3 and 6 months after testing. Multivariable generalized linear marginal models were fit to determine which baseline parameters predict longitudinal changes in symptoms and QOL. RESULTS Overall upper GI symptoms and QOL scores were moderate in severity at baseline and significantly improved over 6 months. Clinical variables, including female gender, harder stools by Bristol stool form score, and presence of functional dyspepsia (FD) by Rome III criteria, were predictive of more severe upper GI symptoms. Even after controlling for these clinical factors, delayed gastric emptying by GES or WMC was associated with worse symptom severity and QOL scores. Low gastric and elevated small bowel contractile parameters by WMC were also independently associated with more severe upper GI symptoms and worse QOL scores. CONCLUSIONS Baseline features, including demographic and clinical variables, delayed gastric emptying and abnormal gastrointestinal contractility, were independent predictors of more severe longitudinal symptoms and worse quality of life outcomes. These factors may help to risk stratify patients and guide treatment decisions. ClinicalTrials.gov no: NCT02022826.
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Affiliation(s)
- Allen A. Lee
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI,Division of Gastroenterology, University of Vermont, Burlington, VT
| | - Krishna Rao
- Division of Infectious Diseases, University of Michigan, Ann Arbor, MI
| | - Henry P. Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA
| | | | - Irene Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, TX
| | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University, Stanford, CA
| | - John M. Wo
- Division of Gastroenterology, Indiana University, Indianapolis, IN
| | | | | | - Satish Rao
- Division of Gastroenterology, Augusta University, Augusta, GA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA
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19
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Vosoughi K, Ichkhanian Y, Benias P, Miller L, Aadam AA, Triggs JR, Law R, Hasler W, Bowers N, Chaves D, Ponte-Neto AM, Draganov P, Yang D, El Halabi M, Sanaei O, Brewer Gutierrez OI, Bulat RS, Pandolfino J, Khashab M. Gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis: results from an international prospective trial. Gut 2022; 71:25-33. [PMID: 33741641 DOI: 10.1136/gutjnl-2020-322756] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Although gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM in unselected patients with refractory gastroparesis. DESIGN In five tertiary centres, patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying were included. The primary endpoint was clinical success, defined as at least one score decrease in Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales, at 12 months. GCSI Score and subscales, adverse events (AEs) and 36-Item Short Form questionnaire of quality of life were evaluated at baseline and 1, 3, 6 and 12 months after G-POEM. Gastric emptying study was performed before and 3 months after the procedure. RESULTS Of 80 enrolled patients, 75 patients (94%) completed 12-month follow-up. Clinical success at 12 months was 56% (95% CI, 44.8 to 66.7). GCSI Score (including subscales) improved moderately after G-POEM (p<0.05). In a regression model, a baseline GCSI Score >2.6 (OR=3.23, p=0.04) and baseline gastric retention >20% at 4 hours (OR=3.65, p=0.03) were independent predictors of clinical success at 12 months, as was early response to G-POEM at 1 month after therapy (OR 8.75, p<0.001). Mild procedure-related AEs occurred in 5 (6%) patients. CONCLUSION G-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry NCT02732821.
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Affiliation(s)
- Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Petros Benias
- Division of Gastroenterology and Hepatology, Northwell Health, New Hyde Park, New York, USA
| | - Larry Miller
- Division of Gastroenterology and Hepatology, Northwell Health, New Hyde Park, New York, USA
| | - A Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Joseph R Triggs
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - William Hasler
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nicole Bowers
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Dalton Chaves
- Division of Gastroenterology and Hepatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Alberto M Ponte-Neto
- Division of Gastroenterology and Hepatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Peter Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida Health, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida Health, Gainesville, Florida, USA
| | - Maan El Halabi
- Department of Medicine, Mount Sinai Saint Luke's Hospital, New York, New York, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA.,Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | | | - Robert Stephen Bulat
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
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20
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Daly A, Hartnell S, Boughton CK, Evans M. Hybrid Closed-loop to Manage Gastroparesis in People With Type 1 Diabetes: a Case Series. J Diabetes Sci Technol 2021; 15:1216-1223. [PMID: 34378426 PMCID: PMC8564229 DOI: 10.1177/19322968211035447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Gastroparesis is associated with unpredictable gastric emptying and can lead to erratic glucose profiles and negative impacts on quality-of-life. Many people with gastroparesis are unable to meet glycemic targets and there is a need for new approaches for this population. Hybrid closed-loop systems improve glucose control and quality-of-life but evidence for their use in people with diabetic gastroparesis is limited. METHODS We present a narrative review of the challenges associated with type 1 diabetes management for people with gastroparesis and present a case series of 7 people with type 1 diabetes and gastroparesis. We compare glycemic control before and during the first 12 months of hybrid closed-loop therapy. Data were analyzed using electronic patient records and glucose management platforms. We also discuss future advancements for closed-loop systems that may benefit this population. RESULTS Five of 7 patients had data available for time in range before and during hybrid closed-loop therapy, and all had an improvement in percentage time in target glucose range, with the overall mean time in range increasing from 26.0% ± 15.7% to 58.4% ± 8.6% during HCL use, (P = .004). There were significant reductions in HbA1c (83 ± 9 mmol/mol to 71 ± 14 mmol/mol) and mean glucose from 13.0 ± 1.7 mmol/L (234 ± 31 mg/dL) to 10.0 ± 0.7 mmol/L (180 ± 13 mg/dL) with use of a hybrid closed-loop system. Importantly, this was achieved without an increase in time in hypoglycemia (P = .50). CONCLUSION Hybrid closed-loop systems may represent a valuable approach to improve glycemic control for people with type 1 diabetes and gastroparesis. Prospective studies are required to confirm these findings.
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Affiliation(s)
- Aideen Daly
- Wellcome Trust-MRC Institute of
Metabolic Science, University of Cambridge, Cambridge, UK
- Aideen Daly, MB BCh, Wellcome Trust-MRC
Institute of Metabolic Science, University of Cambridge, Level 4, Addenbrookes
Hospital, Cambridge, CB2 0QQ, UK.
| | - Sara Hartnell
- Wolfson Diabetes and Endocrine Clinic,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Charlotte K. Boughton
- Wellcome Trust-MRC Institute of
Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark Evans
- Wellcome Trust-MRC Institute of
Metabolic Science, University of Cambridge, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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21
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Gut Hormones as Potential Therapeutic Targets or Biomarkers of Response in Depression: The Case of Motilin. Life (Basel) 2021; 11:life11090892. [PMID: 34575041 PMCID: PMC8465535 DOI: 10.3390/life11090892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022] Open
Abstract
Recent research has identified the gut–brain axis as a key mechanistic pathway and potential therapeutic target in depression. In this paper, the potential role of gut hormones as potential treatments or predictors of response in depression is examined, with specific reference to the peptide hormone motilin. This possibility is explored through two methods: (1) a conceptual review of the possible links between motilin and depression, including evidence from animal and human research as well as clinical trials, based on a literature search of three scientific databases, and (2) an analysis of the relationship between a functional polymorphism (rs2281820) of the motilin (MLN) gene and cross-national variations in the prevalence of depression based on allele frequency data after correction for potential confounders. It was observed that (1) there are several plausible mechanisms, including interactions with diet, monoamine, and neuroendocrine pathways, to suggest that motilin may be relevant to the pathophysiology and treatment of depression, and (2) there was a significant correlation between rs2281820 allele frequencies and the prevalence of depression after correcting for multiple confounding factors. These results suggest that further evaluation of the utility of motilin and related gut peptides as markers of antidepressant response is required and that these molecular pathways represent potential future mechanisms for antidepressant drug development.
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Schol J, Wauters L, Dickman R, Drug V, Mulak A, Serra J, Enck P, Tack J. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. Neurogastroenterol Motil 2021; 33:e14237. [PMID: 34399024 DOI: 10.1111/nmo.14237] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/28/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastroparesis is a condition characterized by epigastric symptoms and delayed gastric emptying (GE) rate in the absence of any mechanical obstruction. The condition is challenging in clinical practice by the lack of guidance concerning diagnosis and management of gastroparesis. METHODS A Delphi consensus was undertaken by 40 experts from 19 European countries who conducted a literature summary and voting process on 89 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation criteria. Consensus (defined as ≥80% agreement) was reached for 25 statements. RESULTS The European consensus defined gastroparesis as the presence of symptoms associated with delayed GE in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms, with often coexisting postprandial distress syndrome symptoms of dyspepsia. The true epidemiology of gastroparesis is not known in detail, but diabetes, gastric surgery, certain neurological and connective tissue diseases, and the use of certain drugs recognized as risk factors. While the panel agreed that severely impaired gastric motor function is present in these patients, there was no consensus on underlying pathophysiology. The panel agreed that an upper endoscopy and a GE test are required for diagnosis. Only dietary therapy, dopamine-2 antagonists and 5-HT4 receptor agonists were considered appropriate therapies, in addition to nutritional support in case of severe weight loss. No consensus was reached on the use of proton pump inhibitors, other classes of antiemetics or prokinetics, neuromodulators, complimentary, psychological, or more invasive therapies. Finally, there was consensus that gastroparesis adversely impacts on quality of life and healthcare costs and that the long-term prognosis of gastroparesis depends on the cause. CONCLUSIONS AND INFERENCES A multinational group of European experts summarized the current state of consensus on definition, symptom characteristics, pathophysiology, diagnosis, and management of gastroparesis.
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Affiliation(s)
- Jolien Schol
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikwa, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vasile Drug
- University of Medicine and Pharmacy Gr T Popa Iasi and University Hospital St Spiridon, Iasi, Romania
| | - Agata Mulak
- Department of Gastroenterology and Hepatology, Wroclaw Medical University, Wroclaw, Poland
| | - Jordi Serra
- Digestive System Research Unit. University Hospital Vall d'Hebron. Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Barcelona, Spain
| | - Paul Enck
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Jan Tack
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Parkman HP, Wilson LA, Yates KP, Koch KL, Abell TL, McCallum RW, Sarosiek I, Kuo B, Malik Z, Schey R, Shulman RJ, Grover M, Farrugia G, Miriel L, Tonascia J, Hamilton F, Pasricha PJ. Factors that contribute to the impairment of quality of life in gastroparesis. Neurogastroenterol Motil 2021; 33:e14087. [PMID: 33493377 PMCID: PMC8310540 DOI: 10.1111/nmo.14087] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/12/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Understanding factors that impair quality of life (QOL) in gastroparesis is important for clinical management. AIMS (a) Determine QOL in patients with gastroparesis; (b) Determine factors that impair QOL. METHODS Gastroparetic patientsAQ6 underwent history and questionnaires assessing symptoms (PAGI-SYM and Rome III), QOL (SF-36v2 and PAGI-QOL), depression (Beck Depression Inventory [BDI]), and anxiety (State Trait Anxiety InventoryAQ7). KEY RESULTS 715 gastroparesis patients (256 diabetic (DG), 459 idiopathic (IG)) were evaluated. SF-36 physical component (PC) score averaged 33.3 ± 10.5; 41% had impaired score <30. SF-36 PC scores were similar between diabetic and idiopathic gastroparesis. Impaired SF-36 PC associated with increased nausea/vomiting and upper abdominal pain subscores, acute onset of symptoms, higher number of comorbidities, use of narcotic pain medications, and irritable bowel syndrome (IBS). SF-36 mental component (MC) score averaged 38.9 ± 13.0; 26% had impaired score <30. Poor SF-36 MC associated with diabetic etiology, higher Beck depression inventory, and state anxiety scores. PAGI-QOL score averaged 2.6 ± 1.1; 50% had a score of <2.6. Low PAGI-QOL associated with higher fullness, bloating, and upper abdominal pain subscores, more depression and Trait anxiety, smoking cigarettes, need for nutritional support, progressively worsening symptoms and periodic exacerbations. CONCLUSIONS & INFERENCES Multiple measures show poor QOL present in gastroparesis. Several areas impacted on reduced QOL: (a) Symptoms of nausea, vomiting, and abdominal pain, as well as IBS; (b) Etiology and acute onset and progressively worsening symptoms; (c) Comorbidities and psychological factors such as anxiety and depression; (d) Patient-related factors such as smoking. Targeting the modifiable factors may improve patient outcomes in gastroparesis.
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Affiliation(s)
| | | | | | | | | | | | - Irene Sarosiek
- Texas Tech University Health Sciences Center, El Paso, TX
| | | | | | | | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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24
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Wolfson S, Wilhelm Z, Opekun AR, Orth R, Shulman RJ, Chumpitazi BP. Clinical Characterization of Pediatric Gastroparesis Using a Four-hour Gastric Emptying Scintigraphy Standard. J Pediatr Gastroenterol Nutr 2021; 72:848-853. [PMID: 33605658 PMCID: PMC8486321 DOI: 10.1097/mpg.0000000000003089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Four-hour gastric emptying scintigraphy (GES) is the recommended method to identify both adult and childhood gastroparesis (GP). Previous pediatric studies have, however, not used this standard. We sought to determine the characteristics and outcomes of children versus adolescents with GP using the 4-hour GES evaluation. METHODS We performed a retrospective chart review of pediatric patients diagnosed with GP by 4-hour GES (>10% retention at 4 hours). Demographics, body mass index, GP-related symptoms, comorbidities, etiologies, therapies (eg, medications), healthcare utilization, and response to therapy were captured systematically. Symptoms were compared from the initial versus last gastroenterology visit. Outcomes were categorized as no improvement; improvement (resolution of at least 1 symptom while remaining on therapy); and complete resolution of symptoms. RESULTS A total of 239 subjects (12.1 ± 4.1 years [mean ± standard deviation], 70% girls) were included. The identified characteristics of childhood GP were broad with idiopathic GP being the most common etiology. Outcomes over a median of 22 months (25%-75%: 9.0-45.5 months) were 34.8% no improvement, 34.8% some improvement, and 30.3% with complete symptom resolution. Compared to younger children, adolescents had a higher female predominance (P < 0.01) and were more likely to have nausea (P = 0.006). Girls were more likely to have abdominal pain (P = 0.001), nausea (P = 0.03), and a documented diagnosis of dysautonomia (P = 0.03). Boys were more likely to have regurgitation (P = 0.006), gastroesophageal reflux disease (P = 0.02), and rumination (P = 0.02). CONCLUSIONS Using the 4-hour GES standard, childhood GP has broad clinical characteristics and outcomes. There are several significant age- and sex-based differences in childhood GP.
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Affiliation(s)
- Sharon Wolfson
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Zoe Wilhelm
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Antone R. Opekun
- Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Department of Medicine, Baylor College of Medicine, Houston, TX USA
| | - Robert Orth
- Department of Radiology, Children’s Hospital of Wisconsin
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Children’s Nutrition Research Center, United States Department of Agriculture, Houston, TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX USA
- Children’s Nutrition Research Center, United States Department of Agriculture, Houston, TX USA
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25
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Schol J, Wauters L, Dickman R, Drug V, Mulak A, Serra J, Enck P, Tack J. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. United European Gastroenterol J 2021; 9:287-306. [PMID: 33939892 PMCID: PMC8259275 DOI: 10.1002/ueg2.12060] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/28/2020] [Indexed: 12/11/2022] Open
Abstract
Background Gastroparesis is a condition characterized by epigastric symptoms and delayed gastric emptying (GE) rate in the absence of any mechanical obstruction. The condition is challenging in clinical practice by the lack of guidance concerning diagnosis and management of gastroparesis. Methods A Delphi consensus was undertaken by 40 experts from 19 European countries who conducted a literature summary and voting process on 89 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation criteria. Consensus (defined as ≥80% agreement) was reached for 25 statements. Results The European consensus defined gastroparesis as the presence of symptoms associated with delayed GE in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms, with often coexisting postprandial distress syndrome symptoms of dyspepsia. The true epidemiology of gastroparesis is not known in detail, but diabetes, gastric surgery, certain neurological and connective tissue diseases, and the use of certain drugs recognized as risk factors. While the panel agreed that severely impaired gastric motor function is present in these patients, there was no consensus on underlying pathophysiology. The panel agreed that an upper endoscopy and a GE test are required for diagnosis. Only dietary therapy, dopamine‐2 antagonists and 5‐HT4 receptor agonists were considered appropriate therapies, in addition to nutritional support in case of severe weight loss. No consensus was reached on the use of proton pump inhibitors, other classes of antiemetics or prokinetics, neuromodulators, complimentary, psychological, or more invasive therapies. Finally, there was consensus that gastroparesis adversely impacts on quality of life and healthcare costs and that the long‐term prognosis of gastroparesis depends on the cause. Conclusions and Inferences A multinational group of European experts summarized the current state of consensus on definition, symptom characteristics, pathophysiology, diagnosis, and management of gastroparesis.
Current knowledge
The epidemiology of gastroparesis is not well known. Diagnosis and treatment of gastroparesis is challenging due to uncertainties in definition and optimal therapeutic approach.
What is new here
A Delphi panel consisting of 40 experts from 19 European countries established the level of consensus on 89 statements regarding gastroparesis. The statements reaching consensus serve to guide clinicians in recognizing, diagnosing and treating gastroparesis in clinical practice. The statements without consensus identify areas in need of future research.
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Affiliation(s)
- Jolien Schol
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikwa, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vasile Drug
- University of Medicine and Pharmacy Gr T Popa Iasi and University Hospital St Spiridon, Iasi, Romania
| | - Agata Mulak
- Department of Gastroenterology and Hepatology, Wroclaw Medical University, Wroclaw, Poland
| | - Jordi Serra
- Digestive System Research Unit. University Hospital Vall d'Hebron. Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Barcelona, Spain
| | - Paul Enck
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Jan Tack
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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26
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Pasricha PJ, Grover M, Yates KP, Abell TL, Bernard CE, Koch KL, McCallum RW, Sarosiek I, Kuo B, Bulat R, Chen J, Shulman RJ, Lee L, Tonascia J, Miriel LA, Hamilton F, Farrugia G, Parkman HP. Functional Dyspepsia and Gastroparesis in Tertiary Care are Interchangeable Syndromes With Common Clinical and Pathologic Features. Gastroenterology 2021; 160:2006-2017. [PMID: 33548234 PMCID: PMC8547190 DOI: 10.1053/j.gastro.2021.01.230] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The aim of this study was to clarify the pathophysiology of functional dyspepsia (FD), a highly prevalent gastrointestinal syndrome, and its relationship with the better-understood syndrome of gastroparesis. METHODS Adult patients with chronic upper gastrointestinal symptoms were followed up prospectively for 48 weeks in multi-center registry studies. Patients were classified as having gastroparesis if gastric emptying was delayed; if not, they were labeled as having FD if they met Rome III criteria. Study analysis was conducted using analysis of covariance and regression models. RESULTS Of 944 patients enrolled during a 12-year period, 720 (76%) were in the gastroparesis group and 224 (24%) in the FD group. Baseline clinical characteristics and severity of upper gastrointestinal symptoms were highly similar. The 48-week clinical outcome was also similar but at this time 42% of patients with an initial diagnosis of gastroparesis were reclassified as FD based on gastric-emptying results at this time point; conversely, 37% of patients with FD were reclassified as having gastroparesis. Change in either direction was not associated with any difference in symptom severity changes. Full-thickness biopsies of the stomach showed loss of interstitial cells of Cajal and CD206+ macrophages in both groups compared with obese controls. CONCLUSIONS A year after initial classification, patients with FD and gastroparesis, as seen in tertiary referral centers at least, are not distinguishable based on clinical and pathologic features or based on assessment of gastric emptying. Gastric-emptying results are labile and do not reliably capture the pathophysiology of clinical symptoms in either condition. FD and gastroparesis are unified by characteristic pathologic features and should be considered as part of the same spectrum of truly "organic" gastric neuromuscular disorders. CLINICALTRIALS. GOV IDENTIFIER NCT00398801, NCT01696747.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Braden Kuo
- Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Bulat
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Linda Lee
- Johns Hopkins University, Baltimore, Maryland
| | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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27
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Meal-Induced Symptoms in Children with Dyspepsia-Relationships to Sex and the Presence of Gastroparesis. J Pediatr 2021; 231:117-123. [PMID: 33359472 PMCID: PMC8500375 DOI: 10.1016/j.jpeds.2020.12.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To test the hypothesis that in children with dyspepsia, prospective symptom severity following ingestion of a meal would correlate with percent gastric retention, and those ultimately diagnosed with gastroparesis would report worse symptoms. STUDY DESIGN Prospective, single-center study with 104 children with dyspepsia completing a prospective dyspepsia symptom questionnaire before and after eating a standardized Tougas meal during gastric emptying scintigraphy. Main outcomes included correlation between gastric retention and symptoms and comparison of symptom severity between those with and without gastroparesis. RESULTS Fifty-two children (50%) had gastroparesis (gastroparesis: 12.5 ± 2.9 years, 65% female; nongastroparesis: 13.0 ± 2.9 years, 60% female; all P > .05). Bloating was the only symptom significantly worse in youth with gastroparesis. For the entire cohort, bloating and fullness correlated with percent retention. However, in those with gastroparesis, only nausea correlated with retention (4 hours.; rs = 0.275, P < .05). Girls with gastroparesis had significantly worse symptoms (except satiety) when compared with boys with gastroparesis (P < .05). CONCLUSIONS Overall in children, there is little difference in symptom severity between children with gastroparesis vs normal emptying based on current standards. However, girls with gastroparesis have worse symptoms vs boys with gastroparesis, underscoring a need for further studies into the role of sex in gastroparesis symptoms. In all children, both bloating and fullness correlated modestly with gastric retention, and nausea correlated in those with gastroparesis.
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28
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Parkman HP, Van Natta M, Yamada G, Grover M, McCallum RW, Sarosiek I, Farrugia G, Koch KL, Abell TL, Kuo B, Miriel L, Tonascia J, Hamilton F, Pasricha PJ. Body weight in patients with idiopathic gastroparesis. Neurogastroenterol Motil 2021; 33:e13974. [PMID: 32930463 PMCID: PMC8180181 DOI: 10.1111/nmo.13974] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/05/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The classic clinical picture of gastroparesis is a symptomatic patient losing weight. In addition, a number of patients with delayed gastric emptying are obese and/or gaining weight. Our aim was to investigate the factors impacting body weight in patients with idiopathic gastroparesis. METHODS In patients with idiopathic gastroparesis, detailed history and weight were acquired at enrollment and after 48 weeks. Questionnaires assessed symptoms, food intake, physical activity, and quality of life. Patients underwent laboratory testing, gastric emptying scintigraphy, and water load testing. RESULTS Of 138 patients with idiopathic gastroparesis, 10% were underweight (BMI < 18.5), 39% were normal weight (BMI 18.5-25), 20% were overweight with BMI 25 to 30 kg/m2 , and 29% were obese with BMI > 30 kg/m2 . Body weight at enrollment was positively associated with oral caloric consumption (P < .001), following a gastroparesis diet (P = .04), nutrition consultation (P = .001), upper abdominal pain (P = .01); and negatively associated with energy expenditure (P = .05), alcohol use (P = .003) and severity of bloating (P < .001). When followed over 48 weeks, 53% patients stayed stable (within 5% of baseline weight), 30% gained, and 17% lost weight. Weight gain over 48 weeks was positively associated with oral caloric consumption (P = .003) and constipation severity (P = .005) at enrollment, and negatively associated with lower abdominal pain severity (P = .007) at enrollment, and associated with improvement in inability to finish meal score (P < .001) at 48 weeks. CONCLUSIONS In this series of patients with idiopathic gastroparesis, 10% were underweight whereas 29% were obese. Over 48 weeks, 30% of patients increased their body weight ≥ 5%. Diet, activity, and symptoms are important factors associated with body weight in patients with idiopathic gastroparesis.
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Affiliation(s)
| | | | | | | | | | - Irene Sarosiek
- Texas Tech University Health Sciences Center, El Paso, TX
| | | | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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29
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Carlin JL, Lieberman VR, Dahal A, Keefe MS, Xiao C, Birznieks G, Abell TL, Lembo A, Parkman HP, Polymeropoulos MH. Efficacy and Safety of Tradipitant in Patients With Diabetic and Idiopathic Gastroparesis in a Randomized, Placebo-Controlled Trial. Gastroenterology 2021; 160:76-87.e4. [PMID: 32693185 DOI: 10.1053/j.gastro.2020.07.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Treatments are needed for gastroparesis; antagonists of tachykinin receptor 1 (TACR1, also called NK1R) can reduce symptoms of nausea and vomiting. We investigated the safety and efficacy of tradipitant, an antagonist of NK1R, in patients with idiopathic or diabetic gastroparesis. METHODS We performed a double-blind trial of 152 adults with gastroparesis at 47 sites in the United States from November 2016 through December 2018. Participants were randomly assigned to groups given oral tradipitant 85 mg (n = 77) or placebo (n = 75) twice daily for 4 weeks. Symptoms were assessed by a daily symptom dairy, Gastroparesis Cardinal Symptom Index scores, and other patient-reported questionnaires. The primary outcome from the intent-to-treat analysis was change from baseline to week 4 in average nausea severity, measured by the Gastroparesis Core Symptom Daily Diary. RESULTS Patients receiving tradipitant had a significant decrease in nausea score (reduction of 1.2) at week 4 compared with placebo (reduction of 0.7) (P = .0099) and a significant increase in of nausea-free days at week 4 (28.8% increase on tradipitant vs 15.0% on placebo; P = .0160). Patients with nausea and vomiting at baseline (n = 101) had an even greater decrease in nausea in when given tradipitant (reduction of 1.4) compared with those given placebo (reduction of 0.4) (P < .0001), as well as an increase in nausea-free days at week 4 (32.3% improvement on tradipitant vs 7.6% on placebo; P = .0003). The average nausea score was 1 or less at week 4 in 32.9% of patients given tradipitant compared with 11.8% of patients given placebo (P = .0013). A greater than 1-point improvement in Gastroparesis Cardinal Symptom Index score was observed in 46.6% of patients given tradipitant compared with 23.5% of patients given placebo (P = .0053). CONCLUSIONS Tradipitant resulted in statistically and clinically meaningful improvements in nausea and reduced vomiting, compared with placebo, in patients with idiopathic or diabetic gastroparesis. ClinicalTrials.gov, Number: NCT02970968.
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Affiliation(s)
| | | | - Arya Dahal
- Vanda Pharmaceuticals, Inc, Washington, DC
| | | | | | | | - Thomas L Abell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, University of Louisville, Louisville, Kentucky
| | - Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Henry P Parkman
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
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30
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Shen S, Luo H, Cai Q. Response to Dr. Frieling. Endoscopy 2021; 53:99. [PMID: 33333575 DOI: 10.1055/a-1214-6170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Shanshan Shen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Hui Luo
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.,State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
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Watts LS, Baker JR, Lee AA, Harer K, Bowers N, Law R, Hasler WL. Impact of gastric per-oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients. Neurogastroenterol Motil 2020; 32:e13892. [PMID: 32542920 DOI: 10.1111/nmo.13892] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Functional Lumen Imaging Probe (EndoFLIP) tests typically measure static pyloric parameters, but the pylorus exhibits phasic variations on manometry. Dynamic changes in pyloric function have not been quantified using EndoFLIP, and the impact of Gastric Per-Oral Endoscopic Myotomy (G-POEM) on static and dynamic pyloric activity in gastroparesis is unknown. METHODS EndoFLIP balloon inflation to 30, 40, and 50 mL was performed to measure mean, maximum, and minimum values and variability in pyloric diameter and distensibility before and after G-POEM in 20 patients with refractory gastroparesis. The impact of phasic contractions on these pyloric measures was compared. KEY RESULTS G-POEM increased mean (P < .0001) and maximum (P = .0002) pyloric diameters and mean (P = .02) and maximum (P = .02) pyloric distensibility on 50 mL EndoFLIP inflation but not intraballoon pressures or minimum diameters or distensibility. Temporal variability of pyloric diameter (P = .02) and distensibility (P = .02) also increased after G-POEM. Phasic coupled contractions propagating from the antrum through the pylorus were observed in 37.5% of recordings; other phasic activity including isolated pyloric contractions were seen in 23.3%. Variability of pyloric diameter and distensibility tended to be higher during recordings with phasic activity. Some pyloric responses to G-POEM were influenced by age, gastroparesis etiology, gastric emptying, and prior botulinum toxin injection. CONCLUSIONS & INFERENCES Pyloric activity exhibits dynamic changes on EndoFLIP testing in gastroparesis. G-POEM increases maximal but not minimal diameter and distensibility with increased variations, suggesting this therapy enhances pyloric opening but may not impair pyloric closure. Phasic pyloric contractions contribute to variations in pyloric activity.
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Affiliation(s)
- Lydia S Watts
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Allen A Lee
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kimberly Harer
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicole Bowers
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
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Hasler WL. Targeting Treatment of Gastroparesis: Use of Clinical Tests to Guide Treatments. Gastroenterol Clin North Am 2020; 49:519-538. [PMID: 32718568 DOI: 10.1016/j.gtc.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastroparesis presents with nausea, vomiting, and other upper gut symptoms, and is diagnosed by confirming delayed gastric emptying. A related condition, chronic unexplained nausea and vomiting, has similar symptoms but with normal emptying. Both conditions are managed using therapies with diverse mechanisms of action. Even though prokinetic treatments are proposed to improve gastroparesis by accelerating gastric emptying, there is limited evidence that they provide benefit by virtue of transit stimulating effects. Other tests can delineate alterations in other gut sensorimotor parameters in patients with suspected gastroparesis, but their relation to symptoms and their capability to guide treatment are largely unproved.
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Affiliation(s)
- William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, 3912 Taubman Center, SPC 5362, Ann Arbor, MI 48109, USA.
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Wang S, Wang R, Zhang Y, Zhang X, Cai B, Lu Y, Xia Y, Chen Q. Therapies for diabetic gastroparesis: A protocol for a systematic review and network meta-analysis. Medicine (Baltimore) 2020; 99:e20461. [PMID: 32481350 PMCID: PMC7249871 DOI: 10.1097/md.0000000000020461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetic gastroparesis (DG) is a common autonomic neuropathy which impacts on nutritional state and quality of life in diabetic patients, and it also adversely affects glycemic control in diabetes. The prevalence of DG is growing with the number of patients with diabetes continues to increase. However, there is no definitive answer as to which of the current therapies is the best for the clinical treatment of the different manifestations of DG. The subject of this study is to answer the following question: what is the best intervention for diabetic patients with gastroparesis? METHODS Comprehensive searches of the Cochrane Library, PubMed, Embase, Medline, Central and Web of Science, and 4 Chinese databases, including China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, Chinese Biomedical Literature Database, and WanFang will be completed using the following keywords DG and therapies and related entry terms. Studies will be included, according to the eligibility criteria (randomized controlled trials and controlled clinical trials, considering specific outcome measures for DG). The reference lists of included studies will be manual searched. Relevant data will be extracted from included studies using a specially designed data extraction sheet. Risk of bias of the included studies will be assessed, and the overall strength of the evidence will be summarized through GRADE. A random effects model will be used for all pairwise meta-analyses (with a 95% confidence interval). A Bayesian network meta-analysis will explore the relative benefits between the various therapies. The review will be reported using the Preferred Reporting Items for Systematic Reviews incorporating Network Meta-Analyses statement. Network meta-analysis will be performed using a Bayesian framework through the Winbugs software. RESULTS This network meta-analysis will identify the best effective therapy for DG. CONCLUSION This study will compare and evaluate current therapies for DG, and find the best treatment of DG.
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Affiliation(s)
- Shengju Wang
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine
| | - Ruili Wang
- Diabetes Department, Jintang County Traditional Chinese Medicine Hospital, Chengdu
| | - Yanli Zhang
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine
| | - Xu Zhang
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine
| | - Baochao Cai
- Endocrinology Department, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing
| | - Yan Lu
- Department of Endocrinology, Third Affiliated Hospital of Chengdu University of TCM, Chengdu, China
| | - Yuguo Xia
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine
| | - Qiu Chen
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine
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Reflux Symptoms in Gastroparesis: Correlation With Gastroparesis Symptoms, Gastric Emptying, and Esophageal Function Testing. J Clin Gastroenterol 2020; 54:428-438. [PMID: 30762609 DOI: 10.1097/mcg.0000000000001190] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL The goal of this study was to determine the relationship of reflux with gastroparesis (Gp), looking both at symptoms and objective testing. BACKGROUND Gp patients often experience gastroesophageal reflux symptoms. How the severity of reflux correlates with the severity of Gp is not known. STUDY Patients referred to our academic center with symptoms of Gp completed the Patient Assessment of Upper Gastrointestinal Symptoms, Hospital Anxiety and Depression Scale, and Patient Health Questionnaire (PHQ)-15. They underwent 4-hour gastric emptying scintigraphy; and, if indicated, high-resolution esophageal manometry and esophageal pH impedance (EpHI). RESULTS Of 755 patients from July 2013 to May 2018, 432 had Gp with Gastroparesis Cardinal Symptom Index (GCSI) total score of 3.2±0.1 (mean±SEM) and heartburn/regurgitation subscore of 2.0±0.1. A fourth (27.1%) of all Gp patients had moderate to very severe heartburn/regurgitation symptoms. Heartburn/regurgitation subscore had strong correlation with GSCI total score (r=0.56, P<0.01), and weak correlation with 4-hour gastric retention (r=0.11, P=0.02). In total, 103 Gp patients underwent EpHI monitoring; time esophageal pH<4 had no correlation with heartburn/regurgitation subscore. Less than half (41.7%) of the patients undergoing EpHI had gastroesophageal reflux disease by EpHI. Gp patients with gastroesophageal reflux disease had more severe 4-hour gastric retention, and more frequently had decreased lower esophageal sphincter resting pressure and esophageal motility disorders. Heartburn/regurgitation subscore had moderate correlation with somatic symptoms, and weak correlations with anxiety and depression. CONCLUSIONS The severity of reflux symptoms in Gp has strong correlation with GCSI total score, weak correlation with gastric retention, and no correlation with esophageal pH monitoring.
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Reichenbach ZW, Stanek S, Patel S, Ward SJ, Malik Z, Parkman HP, Schey R. Botulinum Toxin A Improves Symptoms of Gastroparesis. Dig Dis Sci 2020; 65:1396-1404. [PMID: 31617132 DOI: 10.1007/s10620-019-05885-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/09/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Pyloric injections of botulinum toxin A (BoNT/A) have shown benefit in open-label studies for patients with gastroparesis but not in randomized trials. We sought to examine the effectiveness of BoNT/A injections in a prospective open-label trial of patients with gastroparesis to assess specific symptom improvements over the course of 6 months. We also wanted to determine if specific biochemical measures including creatinine kinase, lactate dehydrogenase, aldolase, and C-reactive protein suggesting muscular injection could be used to predict successful response to pyloric injections of BoNT/A. METHODS Patients with gastroparesis undergoing pyloric BoNT/A injections for the treatment of symptomatic gastroparesis were enrolled. The patients completed the Gastroparesis Cardinal Symptom Index (GCSI) at the initial encounter and at 1, 3, and 6 months. Blood samples were collected before and 1 h after BoNT/A therapy. RESULTS We enrolled 34 patients for serum analysis of which 25 patients were available for symptom follow-up. Sixty-four percent of patients had an improvement in symptoms at 1 month. Patients with improved GCSI total score at 1 month had an improvement in most individual symptoms evaluated. For patients that improved at 1 month, this improvement often extended up to 6 months (p = 0.04). Serum measures studied did not correlate with clinical outcomes. CONCLUSIONS BoNT/A therapy to the pylorus provided symptomatic improvement at 1 month in 64% of patients. For those patients initially responding, the improvement can last out to 6 months. The biochemical markers did not serve to predict the outcome of injections.
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Affiliation(s)
- Zachary Wilmer Reichenbach
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA. .,Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Medical Education and Research Bldg., 8th Floor, Philadelphia, PA, 19140, USA.
| | - Steven Stanek
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Shyam Patel
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Sara Jane Ward
- Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Medical Education and Research Bldg., 8th Floor, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Ron Schey
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
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Pannemans J, Carbone F, Tack J. Opioids in Gastroparesis: Bystander or Cause? Clin Gastroenterol Hepatol 2020; 18:998-999. [PMID: 31470177 DOI: 10.1016/j.cgh.2019.08.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/18/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Jasper Pannemans
- Translational Research in Gastrointestinal Diseases, KU Leuven, Leuven, Belgium; Gastroenterology and Hepatology Unit, University Hospitals Leuven, Leuven, Belgium
| | - Florencia Carbone
- Translational Research in Gastrointestinal Diseases, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research in Gastrointestinal Diseases, KU Leuven, Leuven, Belgium; Gastroenterology and Hepatology Unit, University Hospitals Leuven, Leuven, Belgium
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Febo‐Rodriguez L, Chumpitazi BP, Shulman RJ. Childhood gastroparesis is a unique entity in need of further investigation. Neurogastroenterol Motil 2020; 32:e13699. [PMID: 31407456 PMCID: PMC7015769 DOI: 10.1111/nmo.13699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite increasing knowledge regarding gastroparesis (GP) in adults, little is known regarding the incidence, prevalence, and natural history of childhood GP. Exacerbating the knowledge gap in pediatric GP is both the lack of normative data for gastric emptying scintigraphy in children and lack of GP-specific pediatric reported outcome measures. PURPOSE The aim of this article was to review the available literature on pediatric GP and identify similarities and differences with studies in adults. We performed a comprehensive search in MEDLINE and Google Scholar from inception to April 2019 for articles published in English using the following combination of keywords: gastroparesis, pediatric gastroparesis, outcomes, metoclopramide, erythromycin, domperidone, cisapride, and gastric neurostimulator. The limited available pediatric data, often retrospective, suggest marked differences between adult and pediatric GP in several aspects including etiology, concomitant co-morbidities (eg, psychiatric disorders), clinical symptom presentation, diagnostic evaluation, response to therapies, and clinical outcome. Further research in pediatric GP is needed and holds the promise to further elucidate the mechanisms of this disorder in children and lead to pediatric-focused therapies.
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Affiliation(s)
- Liz Febo‐Rodriguez
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
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Thompson JS, Hewlett A, Lyden E, Scott JR, McBride C. Patient factors influence surgical options in gastroparesis. Am J Surg 2020; 220:1093-1097. [PMID: 32102759 DOI: 10.1016/j.amjsurg.2020.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patient selection for the diverse surgical procedures for gastroparesis remains poorly defined. Our aim was to evaluate how patient factors have determined our surgical approach to gastroparesis. METHODS 95 patients undergoing 105 surgical procedures for gastroparesis were reviewed. Patient factors were compared across six surgical procedures: gastric neurostimulator, pyloroplasty, neurostimulator plus pyloroplasty, sleeve gastrectomy, gastric bypass and gastrectomy. Global symptom severity was determined preoperatively and at last follow up. RESULTS There were significant differences in etiology, BMI and gastroesophageal reflux across the various operations. Patients undergoing pyloroplasty and gastrectomy; were more likely to have a postsurgical etiology. (p < .05) Patients undergoing sleeve gastrectomy and gastric bypass were more likely to have BMI >35. (p <.05) Those undergoing sleeve gastrectomy were less likely to have gastroesophageal reflux preoperatively. (p <.05) There was no difference in preoperative clinical stage across the procedures. CONCLUSION Patient factors influence choice of procedure in the surgical treatment of gastroparesis. Etiology of gastroparesis, BMI >35 and gastroesophageal reflux are important determinants.
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Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, USA.
| | | | - Elizabeth Lyden
- Department of College of Public Health, University of Nebraska Medical Center, USA
| | - James R Scott
- Department of Surgery, University of Nebraska Medical Center, USA
| | - Corrigan McBride
- Department of Surgery, University of Nebraska Medical Center, USA
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Grover M, Farrugia G, Stanghellini V. Gastroparesis: a turning point in understanding and treatment. Gut 2019; 68:2238-2250. [PMID: 31563877 PMCID: PMC6874806 DOI: 10.1136/gutjnl-2019-318712] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/29/2019] [Accepted: 08/22/2019] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Madhusudan Grover
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gianrico Farrugia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vincenzo Stanghellini
- Department of Digestive Diseases and Department of Medical and Surgical Sciences, Policlinico S.Orsola, University of Bologna, Bologna, Italy
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Jehangir A, Collier A, Shakhatreh M, Malik Z, Parkman HP. Caregiver Burden in Gastroparesis and GERD: Correlation with Disease Severity, Healthcare Utilization and Work Productivity. Dig Dis Sci 2019; 64:3451-3462. [PMID: 31300995 DOI: 10.1007/s10620-019-05723-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/03/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Caregiver burden can be significant in chronic gastrointestinal diseases. No studies have been performed to evaluate caregiver burden in gastroparesis or gastroesophageal reflux disease (GERD). AIMS (1) Assess the caregiver burden in gastroparesis and GERD patients and healthy volunteers (HVs); (2) correlate the caregiver burden of these patients to the severity of patients' symptoms, healthcare utilization, and work productivity of the patients and the caregivers. METHODS Patients with gastroparesis and GERD, seen between June 2018 and November 2018, completed Patient Assessment of Gastrointestinal Symptoms, Work Productivity and Activity Impairment (WPAI) and healthcare utilization questionnaires. The caregivers of these patients completed Zarit Burden Interview (ZBI) and WPAI questionnaire. HVs and their potential caregivers also completed these questionnaires. RESULTS Forty-seven patients (gastroparesis = 31, GERD = 17), 12 HVs, and their caregivers completed questionnaires. Caregivers of gastroparesis patients reported high burden on ZBI (27.7 ± 2.9), greater than the caregivers of GERD (14.9 ± 2.5) and HVs (5.5 ± 1.6, p < 0.01). Among all patients, the caregiver burden had a strong correlation with patients' Gastroparesis Cardinal Symptom Index (GCSI) total score (rs = 0.63, p < 0.01) and moderate correlations with the number of patients' physician office visits (rs = 0.46, p < 0.01) and the number of work hours missed by caregivers due to patients' symptoms (rs = 0.36, p = 0.04). Using multivariable regression, both presence of gastroparesis and other comorbidities significantly predicted caregiver burden, F(2, 33) = 15.94, p < 0.0001, R2 = 0.491. CONCLUSIONS Caregivers of gastroparesis patients have high caregiver burden that strongly correlates with patients' GCSI total score. Interventions to reduce symptom severity of Gp patients may reduce the caregiver burden.
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Affiliation(s)
- Asad Jehangir
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
| | - Alexis Collier
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Mohammed Shakhatreh
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
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Abell TL, Yamada G, McCallum RW, Van Natta ML, Tonascia J, Parkman HP, Koch KL, Sarosiek I, Farrugia G, Grover M, Hasler W, Nguyen L, Snape W, Kuo B, Shulman R, Hamilton FA, Pasricha PJ. Effectiveness of gastric electrical stimulation in gastroparesis: Results from a large prospectively collected database of national gastroparesis registries. Neurogastroenterol Motil 2019; 31:e13714. [PMID: 31584238 PMCID: PMC6863164 DOI: 10.1111/nmo.13714] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 08/01/2019] [Accepted: 08/18/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastric electrical stimulation (GES) for treating gastroparesis symptoms is controversial. METHODS We studied 319 idiopathic or diabetic gastroparesis symptom patients from the Gastroparesis Clinical Research Consortium (GpCRC) observational studies: 238 without GES and 81 with GES. We assessed the effects of GES using change in GCSI total score and nausea/vomiting subscales between baseline and 48 weeks. We used propensity score methods to control for imbalances in patient characteristics between comparison groups. KEY RESULTS GES patients were clinically worse (40% severe vs. 18% for non-GES; P < .001); worse PAGI-QOL (2.2. vs. 2.6; P = .003); and worse GCSI total scores (3.5 vs. 2.8; P < .001). We observed improvements in 48-week GCSI total scores for GES vs. non-GES: improvement by ≥ 1-point (RR = 1.63; 95% CI = (1.14, 2.33); P = .01) and change from enrollment (difference = -0.5 (-0.8, -0.3); P < .001). When adjusting for patient characteristics, symptom scores were smaller and not statistically significant: improvement by ≥ 1-point (RR = 1.29 (0.88, 1.90); P = .20) and change from the enrollment (difference = -0.3 (-0.6, 0.0); P = .07). Of the individual items, the nausea improved by ≥ 1 point (RR = 1.31 (1.03, 1.67); P = .04). Patients with GCSI score ≥ 3.0 tended to improve more than those with score < 3.0. (Adjusted P = 0.02). CONCLUSIONS AND INFERENCES This multicenter study of gastroparesis patients found significant improvements in gastroparesis symptoms among GES patients. Accounting for imbalances in patient characteristics, only nausea remained significant. Patients with greater symptoms at baseline improved more after GES. A much larger sample of patients is needed to fully evaluate symptomatic responses and to identify patients likely to respond to GES.
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Affiliation(s)
- Thomas L. Abell
- Digestive Diseases, University of Louisville, Louisville, KY
| | | | | | | | | | | | | | | | | | | | | | | | | | - Braden Kuo
- Massachusetts General Hospital, Boston, MA
| | - Robert Shulman
- Texas Children’s Hospital, Houston TX, Baylor University, Waco, TX
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Bharucha AE, Kudva YC, Prichard DO. Diabetic Gastroparesis. Endocr Rev 2019; 40:1318-1352. [PMID: 31081877 PMCID: PMC6736218 DOI: 10.1210/er.2018-00161] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023]
Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Shakhatreh M, Jehangir A, Malik Z, Parkman HP. Metoclopramide for the treatment of diabetic gastroparesis. Expert Rev Gastroenterol Hepatol 2019; 13:711-721. [PMID: 31314613 DOI: 10.1080/17474124.2019.1645594] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Gastroparesis is a chronic disorder of the stomach characterized by delayed gastric emptying without mechanical obstruction. Diabetes is the most commonly known cause of gastroparesis. Management of diabetic gastroparesis involves lifestyle modifications, glycemic control, pharmacological drugs, and for refractory cases surgical treatments. Metoclopramide remains the only drug approved by the Food and Drug Administration for diabetic gastroparesis. The aim of this article is to provide a concise review of the pharmacology, clinical efficacy and tolerability of metoclopramide. Areas covered: We searched PubMed using the key words 'metoclopramide', 'diabetic gastroparesis', and 'gastric emptying'. The relevant articles and their bibliography were reviewed. Metoclopramide acts on several different receptors; primarily as a dopamine receptor antagonist, both peripherally improving gastric emptying, and centrally resulting in an anti-emetic effect. Metoclopramide side effects, mostly related to its ability to cross the blood-brain barrier, include drowsiness, restlessness, hyperprolactinemia, and tardive dyskinesia (TD), a movement disorder that may be irreversible. Expert opinion: Metoclopramide carries a black box warning for use >12 weeks due to the risk of TD. However, gastroparesis patients experience chronic symptoms often requiring prolonged treatments. Physicians and patients look forward to FDA approval of new agents for gastroparesis with better efficacy and safety profile.
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Affiliation(s)
- Mohammed Shakhatreh
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Asad Jehangir
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Zubair Malik
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Henry P Parkman
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
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Durcan R, Donaghy PC, Barnett NA, Olsen K, Yarnall AJ, Taylor JP, McKeith I, O'Brien JT, Thomas AJ. Prevalence and severity of symptoms suggestive of gastroparesis in prodromal dementia with Lewy bodies. Int J Geriatr Psychiatry 2019; 34:990-998. [PMID: 30901488 DOI: 10.1002/gps.5100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/17/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Lewy body disease is postulated, by the Braak model, to originate in the enteric nervous system, before spreading to the central nervous system. Therefore, a high prevalence of gastroparesis symptoms would be expected in prodromal dementia with Lewy bodies (DLB) and be highest in those with a dopaminergic deficit on imaging. The aim of this study was to explore whether gastroparesis symptoms are an early diagnostic marker of prodromal DLB and explore the relationship between symptoms and dopaminergic imaging findings on FP-CIT SPECT. METHODS We recruited 75 patients over 60 with mild cognitive impairment (MCI), 48 with MCI with suspected Lewy body disease (MCI-LB) and 27 with MCI with suspected Alzheimer's disease (MCI-AD). All patients completed the Gastroparesis Cardinal Symptom Index (GSCI) questionnaire and also underwent FP-CIT [123 I-N-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)] dopaminergic imaging. RESULTS At least one symptom suggestive of gastroparesis was reported in 48% (n = 23) MCI-LB vs 37% MCI-AD (n = 10) (P = 0.36). Rates of definite symptoms of gastroparesis, as defined by a GCSI total score ≥ 1.90, were rare and rates in MCI-LB were not different from MCI-AD (6% vs 0%, p = 0.55). After adjusting for gender differences between groups, no difference in gastroparesis symptom prevalence (2.27 vs 0.81 P = 0.05) or severity score (0.62 vs 0.28, p = 0.28) was noted between normally and abnormally visually rated FP-CIT SPECT scans. CONCLUSION The GCSI is not a useful tool for differentiating MCI-LB from MCI-AD. A low rate of definite gastroparesis was detected in prodromal DLB. No association was found between gastroparesis symptoms and FP-CIT SPECT findings.
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Affiliation(s)
- Rory Durcan
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Paul C Donaghy
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Nicky A Barnett
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Kirsty Olsen
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - John-Paul Taylor
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Ian McKeith
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Alan J Thomas
- Institute of Neuroscience, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
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Parkman HP, Yamada G, Van Natta ML, Yates K, Hasler WL, Sarosiek I, Grover M, Schey R, Abell TL, Koch KL, Kuo B, Clarke J, Farrugia G, Nguyen L, Snape WJ, Miriel L, Tonascia J, Hamilton F, Pasricha PJ, McCallum RW. Ethnic, Racial, and Sex Differences in Etiology, Symptoms, Treatment, and Symptom Outcomes of Patients With Gastroparesis. Clin Gastroenterol Hepatol 2019; 17:1489-1499.e8. [PMID: 30404035 PMCID: PMC6500483 DOI: 10.1016/j.cgh.2018.10.050] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 10/22/2018] [Accepted: 10/28/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Gastroparesis is a chronic disorder of the stomach characterized by nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. There is limited information on gastroparesis in minority populations. We assessed ethnic, racial, and sex variations in the etiology, symptoms, quality of life, gastric emptying, treatments, and symptom outcomes of patients with gastroparesis. METHODS We collected information from the National Institutes of Health Gastroparesis Consortium on 718 adult patients, from September 2007 through December 2017. Patients were followed every 4 or 6 months, when data were collected on medical histories, symptoms (based on answers to the PAGI-SYM questionnaires), and quality of life (based on SF-36). Follow-up information collected at 1 year (48 week) was used in this analysis. Comparisons were made between patients of self-reported non-Hispanic white, non-Hispanic black, and Hispanic ethnicities, as well as and between male and female patients. RESULTS Our final analysis included 552 non-Hispanic whites (77%), 83 persons of Hispanic ethnicity (12%), 62 non-Hispanic blacks (9%), 603 women (84%), and 115 men (16%). A significantly higher proportion of non-Hispanic blacks (60%) had gastroparesis of diabetic etiology than of non-Hispanic whites (28%); non-Hispanic blacks also had more severe retching (2.5 vs 1.7 score) and vomiting (2.9 vs 1.8 score) and a higher percentage were hospitalized in the past year (66% vs 38%). A significantly higher proportion of Hispanics had gastroparesis of diabetic etiology (59%) than non-Hispanic whites (28%), but Hispanics had less-severe nausea (2.7 vs 3.3 score), less early satiety (3.0 vs 3.5 score), and a lower proportion used domperidone (8% vs 21%) or had a peripherally inserted central catheter (1% vs 7%). A higher proportion of women had gastroparesis of idiopathic etiology (69%) than men (46%); women had more severe symptoms of stomach fullness (3.6 vs 3.1 score), early satiety (3.5 vs 2.9 score), postprandial fullness (3.7 vs 3.1 score), bloating (3.3 vs 2.6 score), stomach visibly larger (3.0 vs 2.1 score), and upper abdominal pain (2.9 vs 2.4 score). A lower proportion of women were hospitalized in past year (39% vs 53% of men). CONCLUSIONS In patients with gastroparesis, etiologies, symptom severity, and treatments vary among races and ethnicities and between sexes. ClinicalTrials.gov Identifier: NCT01696747.
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Affiliation(s)
- Henry P Parkman
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania.
| | - Goro Yamada
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Mark L Van Natta
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Katherine Yates
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - William L Hasler
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Irene Sarosiek
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Madhusudan Grover
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Ron Schey
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Thomas L Abell
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Kenneth L Koch
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Braden Kuo
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - John Clarke
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Gianrico Farrugia
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Linda Nguyen
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - William J Snape
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Laura Miriel
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - James Tonascia
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Frank Hamilton
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Pankaj J Pasricha
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Richard W McCallum
- Gastroenterology Section, Temple University School of Medicine, Philadelphia, Pennsylvania
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Strijbos D, Keszthelyi D, Smeets FGM, Kruimel J, Gilissen LPL, de Ridder R, Conchillo JM, Masclee AAM. Therapeutic strategies in gastroparesis: Results of stepwise approach with diet and prokinetics, Gastric Rest, and PEG-J: A retrospective analysis. Neurogastroenterol Motil 2019; 31:e13588. [PMID: 30947400 PMCID: PMC6850664 DOI: 10.1111/nmo.13588] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/14/2019] [Accepted: 03/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastroparesis is characterized by abnormal gastric motor function with delayed gastric emptying in the absence of mechanical obstruction. In our tertiary referral center, patients are treated with a stepwise approach, starting with dietary advice and prokinetics, followed by three months of nasoduodenal tube feeding with "gastric rest." When not successful, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) for long-term enteral feeding is placed. AIM To evaluate the effect of this stepwise approach on weight and symptoms. METHODS Analyses of data of all referred gastroparesis patients between 2008 and 2016. KEY RESULTS A total of 86 patients (71% female, 20-87 years [mean 55.8 years]) were analyzed of whom 50 (58%) had adequate symptom responses to diet and prokinetics. The remaining 36 (decompensated gastroparesis) were treated with three months gastric rest. Symptom response rate was 47% (17/36). Significant weight gain was seen in all patients, independent of symptom response. In the remaining 19 symptom non-responders, the enteral feeding was continued through PEG-J. Treatment was effective (symptoms) in 37%, with significant weight gain in all. In 84% of patients, the PEG-J is still in use (mean duration 962 days). CONCLUSIONS AND INFERENCES Following a stepwise treatment approach in gastroparesis, adequate symptom response was reached in 86% of all patients. Weight gain was achieved in all patients, independent of symptom response. Diet and prokinetics were effective with regard to symptoms in 58%, temporary gastric rest in 47%, and PEG-J as third step in 37% of patients.
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Affiliation(s)
- Denise Strijbos
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands,Department of Gastroenterology and HepatologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Fabiënne G. M. Smeets
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Joanna Kruimel
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Lennard P. L. Gilissen
- Department of Gastroenterology and HepatologyCatharina Hospital EindhovenEindhovenThe Netherlands
| | - Rogier de Ridder
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - José M. Conchillo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Ad A. M. Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
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Xing C, Zhao W, Wang Y. A Case of Fulminant Type 1 Diabetes with Gastric and Urinary Retention. Diabetes Ther 2019; 10:291-298. [PMID: 30460498 PMCID: PMC6349281 DOI: 10.1007/s13300-018-0533-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Indexed: 12/03/2022] Open
Abstract
Fulminant type 1 diabetes (fT1D) is a severe subtype of type 1 diabetes which progresses rapidly with islet cells destroyed almost completely within a short period of time. It is often characterized by flu-like or gastrointestinal symptoms at the onset with negative islet-associated autoantibodies, resulting in an absolute deficiency of endogenous insulin secretion. Poor prognosis can be caused by the significantly higher incidence of metabolic disorders (such as severe ion disorders and elevated serum pancreatic enzymes), acute and chronic complications if not diagnosed and treated in a timely manner. We herein describe an fT1D patient with gastric and urinary retention along with severe ion disturbance, whose laboratory tests revealed diabetic ketoacidosis, peripheral neuropathy, retinopathy, nephropathy, and hypoproteinemia.
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Affiliation(s)
- Chuan Xing
- First Endocrinology Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, People's Republic of China
| | - Wenqian Zhao
- First Endocrinology Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, People's Republic of China
| | - Yanjun Wang
- First Endocrinology Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, People's Republic of China.
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Navas CM, Crowell MD, Lacy BE. The willingness of patients with gastroparesis to take risks with medications. Aliment Pharmacol Ther 2019; 49:429-436. [PMID: 30628106 DOI: 10.1111/apt.15112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/02/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastroparesis has a significant negative impact on patients' quality of life. Only one medication is approved for gastroparesis and it is associated with a significant risk of side effects. AIM To assess the willingness of patients to take risks associated with medications to treat gastroparesis symptoms. METHODS We developed a questionnaire to assess medication risk-taking behaviour in patients identified as having documented gastroparesis (consistent symptoms, normal upper endoscopy, delayed gastric emptying). The survey assessed demographics, symptoms, medication use, anxiety, depression and impulsivity. A standard reference gamble evaluated respondents' willingness to take medication risks. RESULTS Two hundred seven questionnaires were mailed to patients, 103 questionnaires were completed. Seventy-six percent were female; the mean age was 48 years; average duration of gastroparesis symptoms was 10 years. Self-reported symptom severity was severe in 52% and moderate in 32%. Gastroparesis patients reported that they would accept a median 13.4% risk of sudden death to cure their symptoms using a hypothetical medication. Self-reported gastroparesis symptom severity and Gastroparesis Cardinal Symptom Index scores correlated significantly with increased willingness to take risks associated with medications to treat gastroparesis, while anxiety was negatively associated. CONCLUSIONS Gastroparesis patients are willing to accept markedly high risks with a hypothetical medication to cure their symptoms. Patients with severe gastroparesis symptoms and higher Gastroparesis Cardinal Symptom Index scores were more willing to take these risks. This study, the first to quantify gastroparesis patients' willingness to accept medication associated risks, should help clinicians through the complex maze of gastroparesis therapies and their associated risks and benefits.
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Affiliation(s)
- Christopher M Navas
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Brian E Lacy
- Section of Gastroenterology, Mayo Clinic, Jacksonville, Florida
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Bekkelund M, Sangnes DA, Gunnar Hatlebakk J, Aabakken L. Pathophysiology of idiopathic gastroparesis and implications for therapy. Scand J Gastroenterol 2019; 54:8-17. [PMID: 30638082 DOI: 10.1080/00365521.2018.1558280] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis. MATERIALS AND METHODS Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases. RESULTS Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment. CONCLUSIONS Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.
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Affiliation(s)
- Mattis Bekkelund
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway
| | - Dag A Sangnes
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Jan Gunnar Hatlebakk
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Lars Aabakken
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Transplantation Medicine , Section for Gastroenterology, Oslo University Hospital , Oslo , Norway
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Shen S, Xu J, Lamm V, Vachaparambil CT, Chen H, Cai Q. Diabetic Gastroparesis and Nondiabetic Gastroparesis. Gastrointest Endosc Clin N Am 2019; 29:15-25. [PMID: 30396524 DOI: 10.1016/j.giec.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroparesis can be divided into diabetic and nondiabetic, and the 3 main causes of gastroparesis are diabetic, postsurgical, and idiopathic. Delayed gastric emptying is the main manifestation of motility disorders for gastroparesis. Symptoms of gastroparesis are nonspecific and severity can vary. Nausea and vomiting are more common in diabetic gastroparesis whereas abdominal pain and early satiety are more frequent in idiopathic gastroparesis. Medication is still the mainstay of treatment of gastroparesis; however, the development of gastric electric stimulation and gastric peroral endoscopic pyloromyotomy brings more options for the treatment of diabetic and nondiabetic gastroparesis.
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Affiliation(s)
- Shanshan Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Jennifer Xu
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA
| | - Vladimir Lamm
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA
| | - Cicily T Vachaparambil
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA
| | - Huimin Chen
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai 200127, China
| | - Qiang Cai
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Atlanta, GA 30322, USA.
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