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Bor S, Kalkan İH, Savarino E, Rao S, Tack J, Pasricha J, Cangemi D, Schol J, Karunaratne T, Ghisa M, Ahuja NK, Lacy B. Prokinetics-safety and efficacy: The European Society of Neurogastroenterology and Motility/The American Neurogastroenterology and Motility Society expert review. Neurogastroenterol Motil 2024; 36:e14774. [PMID: 38462678 DOI: 10.1111/nmo.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Prokinetics are a class of pharmacological drugs designed to improve gastrointestinal (GI) motility, either regionally or across the whole gut. Each drug has its merits and drawbacks, and based on current evidence as high-quality studies are limited, we have no clear recommendation on one class or other. However, there remains a large unmet need for both regionally selective and/or globally acting prokinetic drugs that work primarily intraluminally and are safe and without systemic side effects. PURPOSE Here, we describe the strengths and weaknesses of six classes of prokinetic drugs, including their pharmacokinetic properties, efficacy, safety and tolerability and potential indications.
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Affiliation(s)
- Serhat Bor
- Division of Gastroenterology, School of Medicine & Ege Reflux Study Group, Ege University, Izmir, Turkey
| | - İsmail H Kalkan
- Department of Gastroenterology, School of Medicine, TOBB University of Economics and Technology, Ankara, Turkey
| | - Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Augusta, Georgia, USA
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Cangemi
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jolien Schol
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Tennekon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Matteo Ghisa
- Digestive Endoscopy Unit, Division of Gastroenterology, Padua University Hospital, Padua, Italy
| | - Nitin K Ahuja
- Division of Gastroenterology, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Brian Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Rashid S, Neice M, Canezaro H, Andrus V, Mubashir M, Raza SM, Traylor J, Takei H, Cai Q. Quantification of gastric muscle interstitial cells of Cajal in individuals with and without gastroparesis: a pilot study. Gastroenterol Rep (Oxf) 2024; 12:goae006. [PMID: 38455072 PMCID: PMC10918627 DOI: 10.1093/gastro/goae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 03/09/2024] Open
Affiliation(s)
- Shazia Rashid
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Michelle Neice
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Hailey Canezaro
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Victoria Andrus
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Maryam Mubashir
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Syed Musa Raza
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - James Traylor
- Department of Pathology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
| | - Hidehiro Takei
- Department of Pathology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA 71103, USA
| | - Qiang Cai
- Division of Gastroenterology and Hepatology, Louisiana State University, Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
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Cury J, Smets H, Bouzin C, Doguet P, Vanhoestenberghe A, Delbeke J, Tahry RE, Nonclercq A, Gorza SP. Optical birefringence changes in myelinated and unmyelinated nerves: A comparative study. JOURNAL OF BIOPHOTONICS 2022; 15:e202200028. [PMID: 35703916 DOI: 10.1002/jbio.202200028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 06/15/2023]
Abstract
The measurement of birefringence variations related to nerve activity is a promising label-free technique for sensing compound neural action potentials (CNAPs). While widely applied in crustaceans, little is known about its efficiency on mammal peripheral nerves. In this work, birefringence recordings to detect CNAPs, and Stokes parameters measurements were performed in rat and lobster nerves. While single-trial detection of nerve activity in crustaceans was achieved successfully, no optical signal was detected in rats, even after extensive signal filtering and averaging. The Stokes parameters showed that a high degree of polarization of light is maintained in lobster sample, whereas an almost complete light depolarization occurs in rat nerve. Our results indicate that depolarization itself is not sufficient to explain the absence of birefringence signals in rats. We hypothesize that this absence comes from the myelin sheets, which constraint the birefringence changes to only take place at the nodes of Ranvier.
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Affiliation(s)
- Joaquín Cury
- Opera-photonics, Université Libre de Bruxelles, Brussels, Belgium
- Bio-, Electro- and Mechanical Systems (BEAMS), Université Libre de Bruxelles, Brussels, Belgium
| | - Hugo Smets
- Bio-, Electro- and Mechanical Systems (BEAMS), Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Bouzin
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique (IREC), IREC Imaging Platform (2IP), Brussels, Belgium
| | | | - Anne Vanhoestenberghe
- Aspire Centre for Rehabilitation Engineering and Assistive Technology, University College of London, London, UK
| | - Jean Delbeke
- Department of Neurology, Institute of Neurosciences (IONS), Université Catholique de Louvain, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Riëm El Tahry
- Department of Neurology, Institute of Neurosciences (IONS), Université Catholique de Louvain, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Antoine Nonclercq
- Bio-, Electro- and Mechanical Systems (BEAMS), Université Libre de Bruxelles, Brussels, Belgium
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Quantification of Interstitial Cells of Cajal in the Gastric Muscle of Patients with Gastroparesis at Per-Oral Endoscopic Pyloromyotomy: A Novel Approach for Future Research in Pathogenesis of Gastroparesis. Dig Dis Sci 2022; 67:4492-4499. [PMID: 34993681 DOI: 10.1007/s10620-021-07318-2] [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: 05/07/2021] [Accepted: 10/04/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The role of Interstitial Cells of Cajal (ICC) in the pathogenesis of gastroparesis has been suggested by previous studies due to their involvement in the transmission of neuronal signaling to the smooth muscles of the GI tract. However, studies have been limited by the inability to obtain a gastric muscle sample, since routine endoscopy can only biopsy the mucosa. We present a new technique of muscle biopsy during per-oral endoscopic pyloromyotomy (GPOEM), a novel endoscopic procedure for treatment of gastroparesis. PATIENTS AND METHODS All enrolled patients had diagnosed gastroparesis and had biopsies of the muscular layer at the antrum/pylorus during POEM. All GPOEM procedures took place from August 2019 to December 2019. Various demographic, disease-related, and procedure-related data were collected from chart review. ICC in the biopsy specimen was examined and quantitated. RESULTS Through this method, we readily expose the gastric muscle of 21 patients through dissection of a gastric submucosal tunnel during GPOEM and provide reliable muscle sample for ICC quantification. Average number of ICC were higher in clinical responders (88 ICC ± 63 vs. 39 ICC ± 24, p = 0.02), defined as those who experienced significant improvement in nausea and vomiting symptoms after GPOEM. CONCLUSIONS This study provides a reliable novel biopsy method for safely biopsy gastric muscle for quantitating the number of gastric ICC in patients with gastroparesis. The number of ICC may be related to the outcome of GPOEM therapy. However, further studies with larger number of patients are needed to confirm the results.
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Miller AF, Levy JA, Krauss BS, Gravel CA, Vieira RL, Neuman MI, Monuteaux MC, Rempell RG. Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time? Pediatr Emerg Care 2021; 37:e1265-e1269. [PMID: 31913246 DOI: 10.1097/pec.0000000000001997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Traditionally, patient-reported fasting time has been the primary objective presedation measure of aspiration risk. Recently, gastric ultrasound has been used to assess gastric volume for the determination of aspiration risk in patients undergoing anesthesia in the operative setting. We sought to determine the correlation of gastric volume estimated by point-of-care ultrasound (POCUS) to reported fasting time. METHODS We included children 4 to 18 years of age who presented with an acute traumatic injury. Enrolled children underwent POCUS to calculate gastric volume, which was calculated using a validated formula: Volume (mL) = -7.8 + (3.5 × Cross-sectional Area [CSA]) + (0.127 × Age in months). The CSA was measured (CSA = (anterior-posterior diameter × craniocaudal diameter × π)/4). We analyzed the relationship between time since last reported oral intake and measured gastric volume using Spearman rank correlation (ρ). RESULTS A total of 103 patients with a median age of 10.5 years (interquartile range, 7.3-13.7 years) were enrolled. The gastric antrum was identified and measured in 88 (85%) patients; air obstructing the posterior surface of the gastric antrum prevented measurement in 14 of the 15 remaining patients. We observed a weak inverse correlation between fasting time (either liquid or solid) and estimated gastric volume (ρ = -0.33), with no significant difference based on type of intake (solids, ρ = 0.28; liquids, ρ = 0.22). CONCLUSION Gastric volume can be estimated by POCUS and is not strongly correlated with fasting time in children in the emergency department setting.
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Affiliation(s)
- Andrew F Miller
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Jason A Levy
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Baruch S Krauss
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Cynthia A Gravel
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Rebecca L Vieira
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Mark I Neuman
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Rachel G Rempell
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Dadhich P, Bitar KN. Functional restoration of ex vivo model of pylorus: Co-injection of neural progenitor cells and interstitial cells of Cajal. Stem Cells Transl Med 2020; 9:713-723. [PMID: 32181603 PMCID: PMC7214644 DOI: 10.1002/sctm.19-0316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/28/2020] [Indexed: 12/12/2022] Open
Abstract
Transplantation of neural stem cells is a promising approach in treatment of intestinal dysfunctionality. The interstitial cells of Cajal (ICCs) are also critical in conditions such as pyloric dysfunctionality and gastroparesis. The objective of this study was to replenish neurons and ICCs in a dysfunctional pylorus as cell-based therapy to restore functionality. ICCs and enteric neural progenitor cells (NPCs) were isolated from rat duodenum and transduced with fluorescent proteins. Rat pylorus was harvested, and an ex-vivo neuromuscular dysfunctional model was developed by selective ablation of neurons and ICCs via chemical treatments. Cellular repopulation and restoration of motility were assessed by immunohistochemistry, qPCR, and functional analysis after delivery of fluorescently tagged cells. Chemical treatment of pylorus resulted in significant depletion of ICCs (67%, P = .0024; n = 3) and neural cells (83%, P = .0012; n = 3). Delivered ICCs and NPCs survived and integrated with host muscle layers. Co-injection of ICCs with NPCs exhibited 34.4% (P = .0004; n = 3) and 61.0% (P = .0003; n = 3) upregulation of ANO1 and βIII tubulin, respectively. This regeneration resulted in the restoration of agonist-induced excitatory contraction (82%) and neuron evoked relaxation (83%). The functional studies with specific neuronal nitric oxide (NO) synthase blocker confirmed that restoration of relaxation was NO mediated and neuronally derived. The simultaneous delivery of ICCs observed 35.7% higher neuronal differentiation and functional restoration compared with injection of NPCs alone. Injected NPCs and ICCs integrated into the dysfunctional ex vivo pylorus tissues and restored neuromuscular functionality. The co-transplantation of NPCs and ICCs can be used to treat neurodegenerative disorders of the pylorus.
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Affiliation(s)
- Prabhash Dadhich
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of MedicineWinston‐SalemNorth Carolina
- Program in Neuro‐Gastroenterology and Motility, Wake Forest School of MedicineWinston‐SalemNorth Carolina
| | - Khalil N. Bitar
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of MedicineWinston‐SalemNorth Carolina
- Program in Neuro‐Gastroenterology and Motility, Wake Forest School of MedicineWinston‐SalemNorth Carolina
- Section on Gastroenterology, Wake Forest School of MedicineWinston‐SalemNorth Carolina
- Virginia Tech‐Wake Forest School of Biomedical Engineering and Sciences, Wake Forest School of MedicineWinston‐SalemNorth Carolina
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Usai-Satta P, Bellini M, Morelli O, Geri F, Lai M, Bassotti G. Gastroparesis: New insights into an old disease. World J Gastroenterol 2020. [DOI: 10.3748/wjg.v26.i19.2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
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Usai-Satta P, Bellini M, Morelli O, Geri F, Lai M, Bassotti G. Gastroparesis: New insights into an old disease. World J Gastroenterol 2020; 26:2333-2348. [PMID: 32476797 PMCID: PMC7243643 DOI: 10.3748/wjg.v26.i19.2333] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/08/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis (Gp) is a chronic disease characterized by a delayed gastric emptying in the absence of mechanical obstruction. Although this condition has been reported in the literature since the mid-1900s, only recently has there been renewed clinical and scientific interest in this disease, which has a potentially great impact on the quality of life. The aim of this review is to explore the pathophysiological, diagnostic and therapeutical aspects of Gp according to the most recent evidence. A comprehensive online search for Gp was carried out using MEDLINE and EMBASE. Gp is the result of neuromuscular abnormalities of the gastric motor function. There is evidence that patients with idiopathic and diabetic Gp may display a reduction in nitrergic inhibitory neurons and in interstitial cells of Cajal and/or telocytes. As regards diagnostic approach, 99-Technetium scintigraphy is currently considered to be the gold standard for Gp. Its limits are a lack of standardization and a mild risk of radiation exposure. The C13 breath testing is a valid and safe alternative method. 13C acid octanoic and the 13C Spirulina platensis recently approved by the Food and Drug Administration are the most commonly used diagnostic kits. The wireless motility capsule is a promising technique, but its use is limited by costs and scarce availability in many countries. Finally, therapeutic strategies are related to the clinical severity of Gp. In mild and moderate Gp, dietary modification and prokinetic agents are generally sufficient. Metoclopramide is the only drug approved by the Food and Drug Administration for Gp. However, other older and new prokinetics and antiemetics can be considered. As a second-line therapy, tricyclic antidepressants and cannabinoids have been proposed. In severe cases the normal nutritional approach can be compromised and artificial nutrition may be needed. In drug-unresponsive Gp patients some alternative strategies (endoscopic, electric stimulation or surgery) are available.
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Affiliation(s)
- Paolo Usai-Satta
- Department of Internal Medicine, Division of Gastroenterology, Brotzu Hospital, Cagliari 09124, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56122, Italy
| | - Olivia Morelli
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia 06123, Italy
| | - Francesca Geri
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56122, Italy
| | - Mariantonia Lai
- Gastroenterology Unit, University of Cagliari, Monserrato 09042, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia 06123, Italy
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Duffey K, Hannon M, Yoo J, Perkons N, Intenzo C, Moleski S, DiMarino AJ. The impact of risk factors on gastroparesis at an urban medical center. Ann Gastroenterol 2020; 33:250-256. [PMID: 32382227 PMCID: PMC7196617 DOI: 10.20524/aog.2020.0475] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/29/2020] [Indexed: 12/31/2022] Open
Abstract
Background Gastroparesis is a complex and poorly understood disease. The literature is lacking with respect to the epidemiology of patient comorbidities and their effect on gastric emptying. We aimed to describe the most common comorbid conditions among patients with gastroparesis in an urban population and quantify the effect of these comorbidities on the severity of delayed gastric emptying (DGE). Methods We examined the medical records of all patients diagnosed with gastroparesis at a quaternary care center between 2014 and 2015. The severity of DGE was analyzed after patients were stratified for possible causative etiologies. Likelihood ratio tests were used to assess the significance of demographic and scintigraphic variation in this population. Results Of the 221 patients, 56.1% were Caucasian and 31.7% were African American. Among these patients, 29.4% had evidence of medication-associated gastroparesis, 29.0% had diabetes-associated gastroparesis, and 31.7% had idiopathic disease. African American patients with gastroparesis were more likely to have diabetic gastroparesis than patients of other races (P=0.01). There was a statistically significant relationship between the number of major risk factors and the severity of a patient's DGE (P=0.004). Conclusions Among a diverse urban population, patients with DGE often carry multiple comorbid conditions that serve as risk factors for the development of gastroparesis, including prescriptions for narcotic medications. Greater numbers of these comorbid conditions are associated with more severe disease. Demographics are significantly associated with the etiology and severity of gastroparesis; in particular, African American patients are more likely to have diabetic gastroparesis than patients of other races.
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Affiliation(s)
- Katherine Duffey
- Department of Medicine, Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA (Katherine Duffey, Michelle Hannon)
| | - Michelle Hannon
- Department of Medicine, Division of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA (Katherine Duffey, Michelle Hannon)
| | - Joseph Yoo
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA (Joseph Yoo, Stephanie Moleski, Anthony J. DiMarino)
| | - Nicholas Perkons
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Nicholas Perkons)
| | - Charles Intenzo
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Thomas Jefferson University, Philadelphia, PA (Charles Intenzo), USA
| | - Stephanie Moleski
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA (Joseph Yoo, Stephanie Moleski, Anthony J. DiMarino)
| | - Anthony J DiMarino
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA (Joseph Yoo, Stephanie Moleski, Anthony J. DiMarino)
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Pesce M, Borrelli O, Saliakellis E, Thapar N. Gastrointestinal Neuropathies: New Insights and Emerging Therapies. Gastroenterol Clin North Am 2018; 47:877-894. [PMID: 30337038 DOI: 10.1016/j.gtc.2018.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The bewildering complexity of the enteric nervous system makes it susceptible to develop a wide array of motility disorders, collectively called enteric neuropathies. These gastrointestinal conditions are among the most challenging to manage, mainly given poor characterization of their etiopathophysiology and outcomes. Not surprisingly, therefore, targeted or curative therapies for enteric neuropathies are lacking and management is largely symptomatic. Nonetheless, recent advances in neurogastroenterology have witnessed improvements in established strategies, such as intestinal transplantation and the emergence of new treatments including novel drugs, electrical pacing, and manipulation of fecal microbiota, as well as stem cell and gene therapy.
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Affiliation(s)
- Marcella Pesce
- Neurogastroenterology and Motility Unit, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London WC1N 3JH, UK; Department of Clinical Medicine and Surgery, 'Federico II' University of Naples, Via Pansini 5, Naples 80131, Italy
| | - Osvaldo Borrelli
- Neurogastroenterology and Motility Unit, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Efstratios Saliakellis
- Neurogastroenterology and Motility Unit, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London WC1N 3JH, UK; Stem Cells and Regenerative Medicine, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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11
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Lu KH, Cao J, Oleson S, Ward MP, Phillips R, Powley TL, Liu Z. Vagus nerve stimulation promotes gastric emptying by increasing pyloric opening measured with magnetic resonance imaging. Neurogastroenterol Motil 2018; 30:e13380. [PMID: 29797377 PMCID: PMC6160317 DOI: 10.1111/nmo.13380] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/18/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Vagus nerve stimulation (VNS) is an emerging electroceutical therapy for remedying gastric disorders that are poorly managed by pharmacological treatments and/or dietary changes. Such therapy seems promising as the vagovagal neurocircuitry modulates the enteric nervous system to influence gastric functions. METHODS Here, the modulatory effects of left cervical VNS on gastric emptying in rats were quantified using a (i) feeding protocol in which the animal voluntarily consumed a postfast, gadolinium-labeled meal and (ii) a non-invasive imaging method to measure antral motility, pyloric activity and gastric emptying based on contrast-enhanced magnetic resonance imaging (MRI) and computer-assisted image processing pipelines. KEY RESULTS Vagus nerve stimulation significantly accelerated gastric emptying (sham vs VNS: 29.1% ± 1.5% vs 40.7% ± 3.9% of meal emptied per 4 hours), caused a greater relaxation of the pyloric sphincter (sham vs VNS: 1.5 ± 0.1 vs 2.6 ± 0.4 mm2 cross-sectional area of lumen), and increased antral contraction amplitude (sham vs VNS: 23.3% ± 3.0% vs 32.5% ± 3.0% occlusion), peristaltic velocity (sham vs VNS: 0.50 ± 0.02 vs 0.67 ± 0.03 mm s-1 ), but not its contraction frequency (sham vs VNS: 6.1 ± 0.2 vs 6.4 ± 0.2 contractions per minute, P = .22). The degree to which VNS relaxed the pylorus was positively correlated with gastric emptying rate (r = .5887, P < .001). CONCLUSIONS & INFERENCES The MRI protocol employed in this study is expected to enable advanced preclinical studies to understand stomach pathophysiology and its therapeutics. Results from this study suggest an electroceutical treatment approach for gastric emptying disorders using cervical VNS to control the degree of pyloric sphincter relaxation.
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Affiliation(s)
- Kun-Han Lu
- School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, USA,Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA
| | - Jiayue Cao
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA,Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA
| | - Steven Oleson
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
| | - Matthew P Ward
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA,Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert Phillips
- Department of Psychological Sciences, Purdue University, West Lafayette, IN, USA
| | - Terry L Powley
- Department of Psychological Sciences, Purdue University, West Lafayette, IN, USA,Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA,Correspondence: Zhongming Liu, PhD, Assistant Professor of Biomedical Engineering, Assistant Professor of Electrical and Computer Engineering College of Engineering, Purdue University, 206 S. Martin Jischke Dr. West Lafayette, IN 47907, USA, Phone: +1 765 496 1872, Fax: +1 765 496 1459, . Terry L Powley, PhD, Distinguished Professor of Behavioral Neuroscience, Department of Psychological Sciences, Purdue University, 703 Third Street, West Lafayette, IN 47907, USA, Phone: +1 765 494 6269,
| | - Zhongming Liu
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA,School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, USA,Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA,Correspondence: Zhongming Liu, PhD, Assistant Professor of Biomedical Engineering, Assistant Professor of Electrical and Computer Engineering College of Engineering, Purdue University, 206 S. Martin Jischke Dr. West Lafayette, IN 47907, USA, Phone: +1 765 496 1872, Fax: +1 765 496 1459, . Terry L Powley, PhD, Distinguished Professor of Behavioral Neuroscience, Department of Psychological Sciences, Purdue University, 703 Third Street, West Lafayette, IN 47907, USA, Phone: +1 765 494 6269,
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12
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Mussa BM, Sood S, Verberne AJM. Implication of neurohormonal-coupled mechanisms of gastric emptying and pancreatic secretory function in diabetic gastroparesis. World J Gastroenterol 2018; 24:3821-3833. [PMID: 30228777 PMCID: PMC6141338 DOI: 10.3748/wjg.v24.i34.3821] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/22/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
Recently, diabetic gastroparesis (DGP) has received much attention as its prevalence is increasing in a dramatic fashion and management of patients with DGP represents a challenge in the clinical practice due to the limited therapeutic options. DGP highlights an interrelationship between the gastric emptying and pancreatic secretory function that regulate a wide range of digestive and metabolic functions, respectively. It well documented that both gastric emptying and pancreatic secretion are under delicate control by multiple neurohormonal mechanisms including extrinsic parasympathetic pathways and gastrointestinal (GI) hormones. Interestingly, the latter released in response to various determinants that related to the rate and quality of gastric emptying. Others and we have provided strong evidence that the central autonomic nuclei send a dual output (excitatory and inhibitory) to the stomach and the pancreas in response to a variety of hormonal signals from the abdominal viscera. Most of these hormones released upon gastric emptying to provide feedback, and control this process and simultaneously regulate pancreatic secretion and postprandial glycemia. These findings emphasize an important link between gastric emptying and pancreatic secretion and its role in maintaining homeostatic processes within the GI tract. The present review deals with the neurohormonal-coupled mechanisms of gastric emptying and pancreatic secretory function that implicated in DGP and this provides new insights in our understanding of the pathophysiology of DGP. This also enhances the process of identifying potential therapeutic targets to treat DGP and limit the complications of current management practices.
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Affiliation(s)
- Bashair M Mussa
- Department of Basic Medical Science, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Sanjay Sood
- Department of Basic Medical Science, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates
| | - Anthony JM Verberne
- Department of Medicine, Austin Health, University of Melbourne, Melbourne 3084, Australia
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Lu KH, Cao J, Oleson ST, Powley TL, Liu Z. Contrast-Enhanced Magnetic Resonance Imaging of Gastric Emptying and Motility in Rats. IEEE Trans Biomed Eng 2018; 64:2546-2554. [PMID: 28796602 DOI: 10.1109/tbme.2017.2737559] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The assessment of gastric emptying and motility in humans and animals typically requires radioactive imaging or invasive measurements. Here, we developed a robust strategy to image and characterize gastric emptying and motility in rats based on contrast-enhanced magnetic resonance imaging (MRI) and computer-assisted image processing. The animals were trained to naturally consume a gadolinium-labeled dietgel while bypassing any need for oral gavage. Following this test meal, the animals were scanned under low-dose anesthesia for high-resolution T1-weighted MRI in 7 Tesla, visualizing the time-varying distribution of the meal with greatly enhanced contrast against non-gastrointestinal (GI) tissues. Such contrast-enhanced images not only depicted the gastric anatomy, but also captured and quantified stomach emptying, intestinal filling, antral contraction, and intestinal absorption with fully automated image processing. Over four postingestion hours, the stomach emptied by 27%, largely attributed to the emptying of the forestomach rather than the corpus and the antrum, and most notable during the first 30 min. Stomach emptying was accompanied by intestinal filling for the first 2 h, whereas afterward intestinal absorption was observable as cumulative contrast enhancement in the renal medulla. The antral contraction was captured as a peristaltic wave propagating from the proximal to distal antrum. The frequency, velocity, and amplitude of the antral contraction were on average 6.34 ± 0.07 contractions per minute, 0.67 ± 0.01 mm/s, and 30.58 ± 1.03%, respectively. These results demonstrate an optimized MRI-based strategy to assess gastric emptying and motility in healthy rats, paving the way for using this technique to understand GI diseases, or test new therapeutics in rat models.The assessment of gastric emptying and motility in humans and animals typically requires radioactive imaging or invasive measurements. Here, we developed a robust strategy to image and characterize gastric emptying and motility in rats based on contrast-enhanced magnetic resonance imaging (MRI) and computer-assisted image processing. The animals were trained to naturally consume a gadolinium-labeled dietgel while bypassing any need for oral gavage. Following this test meal, the animals were scanned under low-dose anesthesia for high-resolution T1-weighted MRI in 7 Tesla, visualizing the time-varying distribution of the meal with greatly enhanced contrast against non-gastrointestinal (GI) tissues. Such contrast-enhanced images not only depicted the gastric anatomy, but also captured and quantified stomach emptying, intestinal filling, antral contraction, and intestinal absorption with fully automated image processing. Over four postingestion hours, the stomach emptied by 27%, largely attributed to the emptying of the forestomach rather than the corpus and the antrum, and most notable during the first 30 min. Stomach emptying was accompanied by intestinal filling for the first 2 h, whereas afterward intestinal absorption was observable as cumulative contrast enhancement in the renal medulla. The antral contraction was captured as a peristaltic wave propagating from the proximal to distal antrum. The frequency, velocity, and amplitude of the antral contraction were on average 6.34 ± 0.07 contractions per minute, 0.67 ± 0.01 mm/s, and 30.58 ± 1.03%, respectively. These results demonstrate an optimized MRI-based strategy to assess gastric emptying and motility in healthy rats, paving the way for using this technique to understand GI diseases, or test new therapeutics in rat models.
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Affiliation(s)
- Kun-Han Lu
- School of Electrical and Computer Engineering and Purdue Institute for Integrative NeurosciencePurdue University
| | - Jiayue Cao
- Weldon School of Biomedical Engineering and Purdue Institute for Integrative NeurosciencePurdue University
| | - Steven Thomas Oleson
- Weldon School of Biomedical Engineering and Purdue Institute for Integrative NeurosciencePurdue University
| | - Terry L Powley
- Department of Psychological Sciences and Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA
| | - Zhongming Liu
- Weldon School of Biomedical Engineering, School of Electrical and Computer Engineering, Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA
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Frazer C, Hussey L, Bemker M. Gastrointestinal Motility Problems in Critically Ill Patients. Crit Care Nurs Clin North Am 2017; 30:109-121. [PMID: 29413206 DOI: 10.1016/j.cnc.2017.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Gastrointestinal (GI) motility problems are common complications in critical care patients. GI problems contribute to an increased risk of morbidity and mortality. Toxic megacolon (TM) is a type of acquired megacolon categorized as a medical emergency and includes severe inflammation affecting all layers of the colon wall. The high incidence of GI complications in critically ill patients requires the critical care nurse to provide close monitoring of patients at risk and an acute awareness of the causation, signs and symptoms, and treatment of various GI motility disorders, including gastroparesis, ileus, and TM.
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Affiliation(s)
- Christine Frazer
- College of Health Sciences, School of Nursing, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA.
| | - Leslie Hussey
- College of Health Sciences, School of Nursing, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
| | - Mary Bemker
- College of Health Sciences, School of Nursing, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401, USA
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Paulon E, Nastou D, Jaboli F, Marin J, Liebler E, Epstein O. Proof of concept: short-term non-invasive cervical vagus nerve stimulation in patients with drug-refractory gastroparesis. Frontline Gastroenterol 2017; 8:325-330. [PMID: 29067158 PMCID: PMC5641854 DOI: 10.1136/flgastro-2017-100809] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/17/2017] [Accepted: 04/02/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastric electric stimulation (GES) is a treatment approach to refractory gastroparesis, possibly acting centrally via afferent vagus nerve stimulation (VNS). Non-invasive VNS (nVNS) is a potential alternative to GES that could eliminate the safety risks of or identify likely responders to implantable neurostimulators. OBJECTIVE This open-label proof-of-concept study assessed the effects of nVNS in patients with severe drug-refractory gastroparesis. METHODS Patients used the Gastroparesis Cardinal Symptom Index (GCSI) to grade symptoms in diaries daily for 2 weeks before treatment (baseline) and during ≥3 weeks of nVNS therapy. Adverse events (AEs) were also diarised. Treatment was self-administered using an nVNS device (gammaCore, electroCore) and consisted of 120 s stimulations to the vagus nerve in the neck (two stimulations to each side three times daily during weeks 1 and 2; three stimulations to each side three times daily during week 3 and beyond). Response was defined as a ≥1 point decrease from baseline in GCSI score. RESULTS Thirty-five patients enrolled; 23 were compliant with study procedures and were included in the analysis; 7 continued treatment beyond 3 weeks. Response rates were 35% (8/23) at 3 weeks and 43% (10/23) for the duration of therapy (3-6 weeks). For the entire cohort and the 10 responders, improvements from baseline were noted for mean total GCSI and GCSI subscale scores (nausea/vomiting, postprandial fullness/early satiety, bloating). No serious AEs were reported. CONCLUSIONS These preliminary results provide a signal that nVNS may be useful for treating refractory gastroparesis. Larger controlled studies are warranted.
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Affiliation(s)
- Emma Paulon
- Royal Free London NHS Foundation Trust, London, UK
| | | | | | - Juana Marin
- NIHR-Wellcome Trust Clinical Research Facility, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Eric Liebler
- electroCore, LLC, Basking Ridge, New Jersey, USA
| | - Owen Epstein
- Royal Free London NHS Foundation Trust, London, UK
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Sobrino-Cossío S, Soto-Pérez J, Coss-Adame E, Mateos-Pérez G, Teramoto Matsubara O, Tawil J, Vallejo-Soto M, Sáez-Ríos A, Vargas-Romero J, Zárate-Guzmán A, Galvis-García E, Morales-Arámbula M, Quiroz-Castro O, Carrasco-Rojas A, Remes-Troche J. Post-fundoplication symptoms and complications: Diagnostic approach and treatment. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2017.02.001] [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: 02/07/2023] Open
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Kim H, Kim I, Lee MC, Kim HJ, Lee GS, Kim H, Kim BJ. Effects of Hwangryunhaedok-tang on gastrointestinal motility function in mice. World J Gastroenterol 2017; 23:2705-2715. [PMID: 28487607 PMCID: PMC5403749 DOI: 10.3748/wjg.v23.i15.2705] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/22/2017] [Accepted: 03/20/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the effects of Hwangryunhaedok-tang (HHT) on gastrointestinal (GI) motility in mice.
METHODS The effects of a boiling water extract of HHT (HHTE) on GI motility were investigated by calculating percent intestinal transit rates (ITR%) and gastric emptying (GE) values using Evans Blue and phenol red, respectively, in normal mice and in mice with experimentally induced GI motility dysfunction (GMD). In addition, the effects of the four components of HHT, that is, Gardeniae Fructus (GF), Scutellariae Radix (SR), Coptidis Rhizoma (CR), and Phellodendri Cortex (PC), on GI motility were also investigated.
RESULTS In normal ICR mice, ITR% and GE values were significantly and dose-dependently increased by the intragastric administration of HHTE (0.1-1 g/kg). The ITR% values of GMD mice were significantly lower than those of normal mice, and these reductions were significantly and dose-dependently inhibited by HHTE (0.1-1 g/kg). Additionally, GF, CR, and PC dose-dependently increased ITR% and GE values in normal and GMD mice.
CONCLUSION These results suggest that HHT is a novel candidate for the development of a gastroprokinetic agent for the GI tract.
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Yin J, Xu X, Song G, Han HS, Kim HW, Chen JDZ. Prokinetic effects of a new 5-HT 4 agonist, YKP10811, on gastric motility in dogs. J Gastroenterol Hepatol 2017; 32:625-630. [PMID: 27418395 DOI: 10.1111/jgh.13490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Prokinetics have been considered the first-line medicine for treating delayed gastric emptying. The aim of this study was to explore the effects and mechanisms of a new 5-HT4 receptor agonist, YKP10811, on gastric motility in dogs. METHODS Four experiments were performed in dogs: (i) dose-response effects of YKP10811 on liquid gastric emptying; (ii) effects and mechanisms of YKP10811 on solid gastric emptying delayed by glucagon; (iii) effects of low-dose YKP10811 on antral contractions; and (iv) effects of low-dose YKP10811 on gastric accommodation. RESULTS No adverse events or cardiac dysrhythmia was noted. (i) High-dose YKP10811 (30 mg/kg) accelerated liquid gastric emptying from 15 to 90 min without inducing adverse events or cardiac dysrhythmia. YKP10811 at low doses (0.3, 1, and 3 mg/kg) accelerated gastric emptying in a dose-dependent manner. (ii) YKP10811 (0.1 mg/kg), but not tegaserod (0.3 mg/kg), significantly accelerated glucagon-induced delayed gastric emptying of solid, and the effect was completely blocked by GR113808. (iii) YKP10811 (0.3 mg/kg) enhanced antral contractions. (iv) YKP10811 did not alter gastric accommodation. CONCLUSIONS YKP10811 seems to improve antral contractions and accelerate gastric emptying without altering gastric accommodation in dogs via the 5-HT4 mechanism and is substantially more potent than tegaserod. No adverse events were noted at a dose 300 times the lowest effective dose. YKP10811 may have a therapeutic potential for gastroparesis.
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Affiliation(s)
- Jieyun Yin
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, Texas, USA.,VA Medical Center, Veterans Research and Education Foundation, Oklahoma, Oklahoma, USA
| | - Xiaohong Xu
- VA Medical Center, Veterans Research and Education Foundation, Oklahoma, Oklahoma, USA
| | - Gengqing Song
- VA Medical Center, Veterans Research and Education Foundation, Oklahoma, Oklahoma, USA
| | - Hyun Sil Han
- Non-Clinical Development Group, Division of Pharm Development, SK Life Science, Inc., Fair Lawn, New Jersey, USA
| | - Hong Wook Kim
- Non-Clinical Development Group, Division of Pharm Development, SK Life Science, Inc., Fair Lawn, New Jersey, USA
| | - Jiande D Z Chen
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, Texas, USA
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Delayed Gastric Emptying in Advanced Parkinson Disease: Correlation With Therapeutic Doses. Clin Nucl Med 2017; 42:83-87. [PMID: 27941374 DOI: 10.1097/rlu.0000000000001470] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Gastrointestinal dysfunction is often described in patients with Parkinson disease (PD), and gastrointestinal symptoms are usually attributed to gastroparesis. The consequent delayed gastric emptying (GE) may be an important pharmacokinetic mechanism underlying some of the response fluctuations that develop after long-term levodopa (L-dopa) therapy.The aim of this prospective study was to assess GE time by a liquid meal scintigraphy, in PD patients, and to correlate them with demographic, clinical, and therapeutic data. METHODS Scintigraphy with radiolabeled albumin nanocolloids added to acidified orange juice was performed in 51 consecutive PD patients 1 hour after their usual dopaminergic therapy first dose and after a 12-hour fast. Demographic, neurologic, gastrointestinal, and pharmacologic data were collected. RESULTS Fifty-one patients were divided into 2 groups using the cutoff point obtained in normal subjects (40 minutes): group 1 included 29 patients with GE T½ of 27.60 ± 7.30 minutes (normal), group 2 showed a GE T½ of 84.90 ± 53.80 minutes (delayed). The most striking significant difference between the 2 groups was the dopa-decarboxylase inhibitor mean dose that was significantly higher in the group of patients with delayed GE (201.32 ± 97.26 vs 127.65 ± 79.74; P = 0.005). CONCLUSIONS The impairment of gastric motility, frequently represented in PD patients, occurs in approximately 42% of patients with motor complications. A mechanism that may explain the GE delay is the effect of L-dopa on dopaminergic receptors in the stomach. Therefore, the dosage of dopa-decarboxylase inhibitor, increasing the L-dopa concentration, may contribute to GE delay and its consequent effect on drug delivery and efficacy.
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Sobrino-Cossío S, Soto-Pérez JC, Coss-Adame E, Mateos-Pérez G, Teramoto Matsubara O, Tawil J, Vallejo-Soto M, Sáez-Ríos A, Vargas-Romero JA, Zárate-Guzmán AM, Galvis-García ES, Morales-Arámbula M, Quiroz-Castro O, Carrasco-Rojas A, Remes-Troche JM. Post-fundoplication symptoms and complications: Diagnostic approach and treatment. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:234-247. [PMID: 28065591 DOI: 10.1016/j.rgmx.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/13/2016] [Accepted: 08/16/2016] [Indexed: 12/12/2022]
Abstract
Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.
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Affiliation(s)
- S Sobrino-Cossío
- Servicio de Endoscopia, Hospital Ángeles del Pedregal, Ciudad de México, México.
| | - J C Soto-Pérez
- Clínica de Fisiología Digestiva (Motilab), Clínica Medivalle, Ciudad de México, México; Clínica de Fisiología Digestiva, Hospital Ángeles Metropolitano, Ciudad de México, México; Servicio de Endoscopia, Hospital Central Sur de Alta Especialidad PEMEX, Ciudad de México, México
| | - E Coss-Adame
- Laboratorio de Motilidad y Fisiología Digestiva, Instituto Nacional de Ciencias Médicas y de la Nutrición «Dr. Salvador Zubirán», Ciudad de México, México
| | - G Mateos-Pérez
- Servicio de Endoscopia, Hospital Ángeles del Pedregal, Ciudad de México, México
| | | | - J Tawil
- Departamento de Trastornos Funcionales Digestivos, Gedyt-Gastroenterología Diagnóstica y Terapéutica, Buenos Aires, Argentina
| | - M Vallejo-Soto
- Servicio de Cirugía General, Hospital Ángeles de Querétaro, Querétaro, México
| | - A Sáez-Ríos
- Servicio de Cirugía General, Hospital Central Militar, Ciudad de México, México
| | | | - A M Zárate-Guzmán
- Unidad de Endoscopia, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - E S Galvis-García
- Unidad de Gastroenterología, Hospital Privado, Guadalajara, Jalisco, México
| | - M Morales-Arámbula
- Unidad de Radiología, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - O Quiroz-Castro
- Servicio de Cirugía General, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - A Carrasco-Rojas
- Laboratorio de Motilidad y Fisiología Digestiva, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México
| | - J M Remes-Troche
- Laboratorio de Motilidad y Fisiología Digestiva, Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, México
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Mohammad MK, Pepper DJ, Kedar A, Bhaijee F, Familoni B, Rashed H, Cutts T, Abell TL. Measures of Autonomic Dysfunction in Diabetic and Idiopathic Gastroparesis. Gastroenterology Res 2016; 9:65-69. [PMID: 27785328 PMCID: PMC5040547 DOI: 10.14740/gr713w] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 12/11/2022] Open
Abstract
Background Gastroparesis is a condition classically characterized by delayed gastric emptying and is associated with considerable morbidity. While the etiology of gastroparesis remains elusive, autonomic dysfunction may play an important role, especially as many patients with gastroparesis also have diabetes. The aim of this study was to determine whether measures of autonomic function differ between adults with diabetic gastroparesis (DG) and adults with idiopathic gastroparesis (IG). Methods Tests of systemic autonomic function were performed among 20 adults with GD (six men and 14 women, mean age: 42 years) and 21 adults with IG (seven men and 14 women, mean age: 37 years). Measures included vagal cholinergics by R-R interval percentage variation (RRI-PV) and sympathetic adrenergics by vasoconstriction to cold (VC) and postural adjustment ratio (PAR). The two groups were compared using Wilcoxon rank sum tests and linear regression analysis (STATA 10.0). Results In univariate analysis, the following autonomic measures differed significantly between DG and IG: VC (P = 0.004), PAR (P = 0.045), VC + PAR (P = 0.002) and RRI-PV (P < 0.001). In multivariate analysis (P = 0.002, R2 = 0.55), only RRI-PV (adjusted odds ratio (aOR): 1.02, 95% confidence interval (CI): 1.01 - 1.03) differed significantly between DG and IG patients. Conclusions Vagal cholinergics are affected to a greater degree in DG compared to IG, suggesting that impaired vagal tone is not a universal mechanism for gastroparesis.
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Affiliation(s)
- Mohammad Khalid Mohammad
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Dominique J Pepper
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Critical Care Medicine Department, National Institutes of Health, Bethesda, MD, USA
| | - Archana Kedar
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | | | - Babajide Familoni
- US Army Research, Development and Engineering Command, NVESD, Ft. Belvoir, VA, USA
| | - Hani Rashed
- Neuroscience Institute and Cancer Center, Methodist University Hospital, Memphis, TN, USA
| | - Teresa Cutts
- Division of Public Health, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Thomas L Abell
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
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Wijeratne T, Patel AM, Jowhari F, Wijeratne NT, Paterson WG. Erythromycin and related macrolides for gastroparesis. Hippokratia 2016. [DOI: 10.1002/14651858.cd012154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Thiwanka Wijeratne
- Queen's University; Division of Internal Medicine; 76 Stuart Street Kingston ON Canada K7L 2V7
| | - Akash M Patel
- Queen's University; Division of Gastroenterology; 76 Stuart Street Kingston ON Canada K7L 2V7
| | - Fahd Jowhari
- Queen's University; Division of Gastroenterology; 76 Stuart Street Kingston ON Canada K7L 2V7
| | - Nishardi T Wijeratne
- Queen's University; Division of Psychiatry; 76 Stuart Street Kingston ON Canada K7L 2V7
| | - William G Paterson
- Queen's University; Division of Gastroenterology; 76 Stuart Street Kingston ON Canada K7L 2V7
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Goldstein AM, Thapar N, Karunaratne TB, De Giorgio R. Clinical aspects of neurointestinal disease: Pathophysiology, diagnosis, and treatment. Dev Biol 2016; 417:217-28. [PMID: 27059882 DOI: 10.1016/j.ydbio.2016.03.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 02/07/2023]
Abstract
The enteric nervous system (ENS) is involved in the regulation of virtually all gut functions. Conditions referred to as enteric neuropathies are the result of various mechanisms including abnormal development, degeneration or loss of enteric neurons that affect the structure and functional integrity of the ENS. In the past decade, clinical and molecular research has led to important conceptual advances in our knowledge of the pathogenetic mechanisms of these disorders. In this review we consider ENS disorders from a clinical perspective and highlight the advancing knowledge regarding their pathophysiology. We also review current therapies for these diseases and present potential novel reparative approaches for their treatment.
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Affiliation(s)
- Allan M Goldstein
- Department of Pediatric Surgery, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nikhil Thapar
- Division of Neurogastroenterology and Motility, Department of Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
| | - Tennekoon Buddhika Karunaratne
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences and Gastrointestinal System, University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy; Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna and St. Orsola-Malpighi Hospital, Bologna, Italy
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Foods provoking and alleviating symptoms in gastroparesis: patient experiences. Dig Dis Sci 2015; 60:1052-8. [PMID: 25840923 DOI: 10.1007/s10620-015-3651-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/26/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND Nutritional counseling for gastroparesis focuses on reduction of meal size, fiber, and fat to control symptoms. The tolerance of gastroparesis patients for particular foods is largely anecdotal. The aim of this study was to identify and characterize foods provoking or alleviating gastroparesis symptoms. METHODS Gastroparesis patients completed: (1) Demographic Questionnaire; (2) Patient Assessment of Upper GI Symptoms; (3) Food Toleration and Aversion survey asking patients about experiences when eating certain foods utilizing a scale from -3 (greatly worsening symptoms) to +3 (greatly improving symptoms). Descriptive qualities (acidic, fatty, spicy, roughage-based, bitter, salty, bland, and sweet) were assigned to foods. RESULTS Forty-five gastroparesis patients participated (39 idiopathic gastroparesis). Foods worsening symptoms included: orange juice, fried chicken, cabbage, oranges, sausage, pizza, peppers, onions, tomato juice, lettuce, coffee, salsa, broccoli, bacon, and roast beef. Saltine crackers, jello, and graham crackers moderately improved symptoms. Twelve additional foods were tolerated by patients (not provoking symptoms): ginger ale, gluten-free foods, tea, sweet potatoes, pretzels, white fish, clear soup, salmon, potatoes, white rice, popsicles, and applesauce. Foods provoking symptoms were generally fatty, acidic, spicy, and roughage-based. The foods shown to be tolerable were generally bland, sweet, salty, and starchy. CONCLUSIONS This study identified specific foods that worsen as well as foods that may help alleviate symptoms of gastroparesis. Foods that provoked symptoms differed in quality from foods that alleviated symptoms or were tolerable. The results of this study illustrate specific examples of foods that aggravate or improve symptoms and provide suggestions for a gastroparesis diet.
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Welsh C, Jarrin J, Daneman A, Belik J. In vivo ultrasound assessment of gastric emptying in newborn mice. J Pediatr Gastroenterol Nutr 2015; 60:322-6. [PMID: 25714576 DOI: 10.1097/mpg.0000000000000611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aim of the present study was to develop an ultrasonographic approach to comparatively assess gastric emptying in newborn wild-type and guanosine triphosphate cyclohydrolase knockout hph-1 mice, because we previously reported gastroparesis early in life in this strain. METHODS Stomach transverse, anteroposterior, and longitudinal ultrasonographic measurements were obtained with a 40-MHz transducer in pups immediately after maternal separation and 4 hours later. A conventional equation was used and the predicted values validated by obtaining postmortem gastric content volume measurements. Wild-type and hph-1 mice gastric emptying rates were comparatively evaluated at 1 to 3 and 5 to 8 days of age, respectively. RESULTS The ultrasound equation closely predicted the newborn stomach content volumes with a correlation coefficient (R) of 0.93 and 0.81 (P < 0.01) for measurements obtained on full stomach and after 4 hours of fasting, respectively. In wild-type mice, gastric emptying was age dependent and associated with a greater residual volume at 1 to 3 days (65% ± 7%), as compared with 5- to 8-day-old pups (33% ± 4%; P < 0.01), after fasting. In contrast, an equal duration of fasting resulted in a significantly greater residual gastric content volume in 5- to 8-day-old hph-1 mice (68% ± 7%; P < 0.01), as compared with same-age wild-type mice. CONCLUSIONS Ultrasonography offers a sensitive and accurate estimate of gastric content volume in newborn mice. In wild-type newborn mice, gastric emptying rate is age dependent and significantly reduced in the immediate postnatal period. The newborn hph-1 mice have a significantly higher gastric residual volume, as compared with wild-type same-age animals.
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Affiliation(s)
- Christopher Welsh
- *Physiology & Experimental Medicine Program, Department of Paediatrics †Department of Diagnostic Imaging, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
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Phillips LK, Deane AM, Jones KL, Rayner CK, Horowitz M. Gastric emptying and glycaemia in health and diabetes mellitus. Nat Rev Endocrinol 2015; 11:112-28. [PMID: 25421372 DOI: 10.1038/nrendo.2014.202] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rate of gastric emptying is a critical determinant of postprandial glycaemia and, accordingly, is fundamental to maintaining blood glucose homeostasis. Disordered gastric emptying occurs frequently in patients with longstanding type 1 diabetes mellitus and type 2 diabetes mellitus (T2DM). A complex bidirectional relationship exists between gastric emptying and glycaemia--gastric emptying accounts for ∼35% of the variance in peak postprandial blood glucose concentrations in healthy individuals and in patients with diabetes mellitus, and the rate of emptying is itself modulated by acute changes in glycaemia. Clinical implementation of incretin-based therapies for the management of T2DM, which diminish postprandial glycaemia, in part by slowing gastric emptying, is widespread. Other therapies for patients with T2DM, which specifically target gastric emptying include pramlintide and dietary-based treatment approaches. A weak association exists between upper gastrointestinal symptoms and the rate of gastric emptying. In patients with severe diabetic gastroparesis, pathological changes are highly variable and are characterized by loss of interstitial cells of Cajal and an immune infiltrate. Management options for patients with symptomatic gastroparesis remain limited in their efficacy, which probably reflects the heterogeneous nature of the underlying pathophysiology.
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Affiliation(s)
- Liza K Phillips
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Adam M Deane
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Karen L Jones
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Chris K Rayner
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Discipline of Medicine, The University of Adelaide, Level 6 Eleanor Harrald Building, Royal Adelaide Hospital, Frome Road, Adelaide, SA 5005, Australia
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Yang K, Qiu BY, Yan J, Yang YX, Zhang T, Chen X, Zou YP, Gan HT, Huang XL. Blockade of p38 mitogen-activated protein kinase pathway ameliorates delayed gastric emptying in streptozotocin-induced diabetic rats. Int Immunopharmacol 2014; 23:696-700. [PMID: 25445962 DOI: 10.1016/j.intimp.2014.10.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/20/2014] [Accepted: 10/23/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Gastrointestinal dysfunction is one of the major complications of diabetes. The roles of inflammation in diabetes and its associated complications are increasingly recognized. p38 mitogen-activated protein kinase (MAPK) has been shown to be involved in the production of pro-inflammatory mediators. The aims of this study were to investigate the effects of SB203580, a specific p38 MAPK inhibitor, on delayed gastric emptying in diabetic rats and to elucidate its possible mechanism. METHODS SB203580 was administered in diabetic rats induced by intraperitoneal injection of streptozotocin. The gastric emptying rate of rats was measured by using phenol red solution, and blood glucose levels and body weights were observed. p38 MAPK activity and iNOS expression were assessed by Western blot analysis. The expression of tumor necrosis factor (TNF)-α and interleukin (IL)-1β were determined by enzyme-linked immunosorbent assay. RESULTS Gastric emptying was delayed significantly in diabetic rats and improved significantly with SB203580; high glucose significantly activated p38 MAPK and increased the expression of iNOS, TNF-α and IL-1β. The administration of SB203580 led to a significant decrease in the activation of p38 MAPK and the expression of iNOS, TNF-α and IL-1β. CONCLUSIONS Inflammation was associated with the development of delayed gastric emptying, and blockade of p38 MAPK pathway with SB203580 ameliorates delayed gastric emptying in diabetic rats, at least in part, by inhibiting the expression of iNOS, TNF-a and IL-1β. Therefore, p38MAPK may serve as a novel target for the therapy of diabetes-related gastrointestinal dysmotility.
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Affiliation(s)
- Kun Yang
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bo Yun Qiu
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Yan
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying Xue Yang
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhang
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xi Chen
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Pei Zou
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hua Tian Gan
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao Li Huang
- Department of Geriatrics Medicine and Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Greene JG. Causes and consequences of degeneration of the dorsal motor nucleus of the vagus nerve in Parkinson's disease. Antioxid Redox Signal 2014; 21:649-67. [PMID: 24597973 DOI: 10.1089/ars.2014.5859] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
SIGNIFICANCE Parkinson's disease (PD) is no longer considered merely a movement disorder caused by degeneration of dopamine neurons in the midbrain. It is now recognized as a widespread neuropathological syndrome accompanied by a variety of motor and nonmotor clinical symptoms. As such, any hypothesis concerning PD pathogenesis and pathophysiology must account for the entire spectrum of disease and not solely focus on the dopamine system. RECENT ADVANCES Based on its anatomy and the intrinsic properties of its neurons, the dorsal motor nucleus of the vagus nerve (DMV) is uniquely vulnerable to damage from PD. Fibers in the vagus nerve course throughout the gastrointestinal (GI) tract to and from the brainstem forming a close link between the peripheral and central nervous systems and a point of proximal contact between the environment and areas where PD pathology is believed to start. In addition, DMV neurons are under high levels of oxidative stress due to their high level of α-synuclein expression, fragile axons, and specific neuronal physiology. Moreover, several consequences of DMV damage, namely, GI dysfunction and unrestrained inflammation, may propagate a vicious cycle of injury affecting vulnerable brain regions. CRITICAL ISSUES Current evidence to suggest the vagal system plays a pivotal role in PD pathogenesis is circumstantial, but given the current state of the field, the time is ripe to obtain direct experimental evidence to better delineate it. FUTURE DIRECTIONS Better understanding of the DMV and vagus nerve may provide insight into PD pathogenesis and a neural highway with direct brain access that could be harnessed for novel therapeutic interventions.
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Affiliation(s)
- James G Greene
- Department of Neurology, Emory University , Atlanta, Georgia
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Yin J, Song J, Lei Y, Xu X, Chen JDZ. Prokinetic effects of mirtazapine on gastrointestinal transit. Am J Physiol Gastrointest Liver Physiol 2014; 306:G796-801. [PMID: 24627566 DOI: 10.1152/ajpgi.00130.2013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mirtazapine is a noradrenergic and specific serotonergic antidepressant. The aim of this study was to investigate the effects of mirtazapine on gastrointestinal motility in dogs, including solid gastric emptying, antral and small intestinal contractions, and small intestinal and colonic transit. Six dogs were implanted with two cannulas located at the duodenum and the ascending colon; another six dogs were implanted with gastric cannula 6 cm proximal to the pylorus. Mirtazapine 45 mg was administered orally 90 min before the study. We found that 1) Mirtazapine accelerated gastric emptying during the entire 3 h in normal dogs (P < 0.04) and accelerated delayed gastric emptying induced by rectal distention (P < 0.04). 2) Mirtazapine restored impaired gastric tone and accommodation induced by rectal distention (P < 0.05). 3) No significant changes were noted in small intestinal contractions or transit with mirtazapine (P > 0.1). 4) Mirtazapine accelerated colonic transit at 2 and 4 h but not 6 h. The geometric center was increased from 1.9 ± 0.6 to 3.0 ± 0.5 and 3.9 ± 0.5 to 4.7 ± 0.1 at 2 and 4 h respectively (P = 0.04 vs. corresponding control). In conclusion, mirtazapine improves gastric emptying in healthy dogs and normalizes rectal distention-induced delay in gastric emptying and accelerates colon but not small intestinal transit in healthy dogs. Clinical studies are warranted to assess the effects of mirtazapine on gastrointestinal motility and sensory functions in patients with functional gastrointestinal diseases.
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Affiliation(s)
- Jieyun Yin
- Division of Gastroenterology, University of Texas Medical Branch, Galveston, Texas
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Homko CJ, Zamora LC, Boden G, Parkman HP. Bodyweight in patients with idiopathic gastroparesis: roles of symptoms, caloric intake, physical activity, and body metabolism. Neurogastroenterol Motil 2014; 26:283-9. [PMID: 24286121 DOI: 10.1111/nmo.12263] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 10/23/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most gastroparetic patients are underweight probably because of frequently experienced early satiety, nausea, and vomiting. Some gastroparesis (GP) patients, however, are overweight, for reasons that are not well understood. The aim of this study was to evaluate the factors that influence bodyweight such as resting energy and exercise-related expenditure, symptoms of early satiety, nausea and vomiting, and caloric intake in patients with idiopathic GP and in healthy controls. METHODS Thirty-nine healthy controls and 29 subjects with idiopathic GP were studied. Resting energy expenditure (indirect calorimetry), body composition (bioelectrical impedance), dietary intake (Block Food Frequency Questionnaire), symptoms (Patient Assessment of Upper GI Symptoms), and physical activity (Paffenbarger exercise survey) were assessed. KEY RESULTS Both median caloric intake (1242 vs 1804 kcal; p = 0.005) and caloric expenditure (486 vs 2172 kcal; p < 0.01) were significantly lower in patients with GP as compared to controls although BMI (25.8 ± 5.8 vs 24.3 ± 4.0 kg/m²) and resting energy expenditure (1327 ± 293 vs 1422 ± 243 kcal) were similar. On the other hand, the 12 GP patients who had gained weight (GW) since diagnosis had lower symptom severity (12.9 ± 4.4 vs 19.3 ± 6.3; p < 0.05), consumed more calories (1342 vs 1134 kcal; p = 0.08) and expended less calories for activity per week (406 vs 644 median kcal; p = 0.45) compared to the 17 GP patients who had lost weight or remained weight neutral (LW). CONCLUSIONS & INFERENCES Patients with GP, although in energy balance, consumed and expended less calories than healthy controls. A subgroup of patients with GP who were less symptomatic, gained weight because of increased caloric intake and reduced energy expenditure.
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Affiliation(s)
- C J Homko
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA; Sections of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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Kotani K, Kawabe J, Kawamura E, Kawano N, Emoto M, Yoshida A, Higashiyama S, Morioka T, Inaba M, Shiomi S. Clinical assessment of delayed gastric emptying and diabetic complications using gastric emptying scintigraphy: Involvement of vascular disorder. Clin Physiol Funct Imaging 2013; 34:151-8. [DOI: 10.1111/cpf.12079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 07/09/2013] [Indexed: 12/19/2022]
Affiliation(s)
- Kohei Kotani
- Department of Nuclear Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Joji Kawabe
- Department of Nuclear Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Etsushi Kawamura
- Department of Hepatology; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Naoya Kawano
- Department of Metabolism, Endocrinology and Molecular Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Atsushi Yoshida
- Department of Nuclear Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Shigeaki Higashiyama
- Department of Nuclear Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Tomoaki Morioka
- Department of Metabolism, Endocrinology and Molecular Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
| | - Susumu Shiomi
- Department of Nuclear Medicine; Graduate School of Medicine; Osaka City University; Osaka Japan
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Koziolek M, Garbacz G, Neumann M, Weitschies W. Simulating the Postprandial Stomach: Physiological Considerations for Dissolution and Release Testing. Mol Pharm 2013; 10:1610-22. [DOI: 10.1021/mp300604u] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Mirko Koziolek
- Institute of Pharmacy, Department
of Biopharmaceutics and Pharmaceutical Technology, Center of Drug
Absorption and Transport, University of Greifswald, Felix-Hausdorff-Strasse
3, 17487 Greifswald, Germany
| | - Grzegorz Garbacz
- Physiolution GmbH, Walther-Rathenau-Strasse
49a, 17489 Greifswald, Germany
| | - Marco Neumann
- Institute of Pharmacy, Department
of Biopharmaceutics and Pharmaceutical Technology, Center of Drug
Absorption and Transport, University of Greifswald, Felix-Hausdorff-Strasse
3, 17487 Greifswald, Germany
| | - Werner Weitschies
- Institute of Pharmacy, Department
of Biopharmaceutics and Pharmaceutical Technology, Center of Drug
Absorption and Transport, University of Greifswald, Felix-Hausdorff-Strasse
3, 17487 Greifswald, Germany
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O'Loughlin PM, Gilliam AD, Shaban F, Varma JS. Pre-operative gastric emptying time correlates with clinical response to gastric electrical stimulation in the treatment of gastroparesis. Surgeon 2012. [PMID: 23206591 DOI: 10.1016/j.surge.2012.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Gastric electrical stimulation (GES) may be of benefit in cases of gastroparesis that fail to respond to standard medical therapy. Response to this treatment is varied and prediction of clinical improvement is difficult. METHODS This was a retrospective review and symptom questionnaire survey for all patients who underwent GES insertion in a single institution from November 2008 until May 2010 using the gastroparesis cardinal symptom index (GCSI). RESULTS 14 out of 17 patients who had GES insertion responded to telephone or postal questionnaire. Mean pre-operative gastric emptying time was 151 min (median 146 min, range 18-318). Median follow up was 14 months (range 7-25 months). The mean reduction in GCSI score after GES insertion was 51% (13.4 vs 6.4, Z = 0.0013). Percentage reduction in GCSI correlated with pre-operative solid gastric emptying time (p = 0.0086). Two patients who responded to questionnaire required device removal, one due to a gastric perforation and the other for discomfort related to the implant and a poor clinical response. CONCLUSIONS GES significantly improves symptoms of gastroparesis on the GCSI score. Not all patients respond equally to GES, and response may be predicted by pre-operative solid gastric emptying times.
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Affiliation(s)
- P M O'Loughlin
- Department of General Surgery, Darlington Memorial Hospital, Hollyhurst Road, Darlington DL3 6HX, UK.
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Noorian AR, Rha J, Annerino DM, Bernhard D, Taylor GM, Greene JG. Alpha-synuclein transgenic mice display age-related slowing of gastrointestinal motility associated with transgene expression in the vagal system. Neurobiol Dis 2012; 48:9-19. [DOI: 10.1016/j.nbd.2012.06.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/27/2012] [Accepted: 06/07/2012] [Indexed: 12/29/2022] Open
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Gatopoulou A, Papanas N, Maltezos E. Diabetic gastrointestinal autonomic neuropathy: current status and new achievements for everyday clinical practice. Eur J Intern Med 2012; 23:499-505. [PMID: 22863425 DOI: 10.1016/j.ejim.2012.03.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 02/27/2012] [Accepted: 03/01/2012] [Indexed: 12/14/2022]
Abstract
Gastrointestinal symptoms occur frequently among patients with diabetes mellitus and are associated with considerable morbidity. Diabetic gastrointestinal autonomic neuropathy represents a complex disorder with multifactorial pathogenesis, which is still not well understood. It appears to involve a spectrum of metabolic and cellular changes that affect gastrointestinal motor and sensory control. It may affect any organ in the digestive system. Clinical manifestations are often underestimated, and therefore autonomic neuropathy should be suspected in all diabetic patients with unexplained gastrointestinal symptoms. Advances in technology have now enabled assessment of gastrointestinal motor function. Moreover, novel pharmacological approaches, along with endoscopic and surgical treatment options, contribute to improved outcomes. This review summarises the progress achieved in diabetic gastrointestinal autonomic neuropathy during the last years, focusing on clinical issues of practical importance to the everyday clinician.
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Affiliation(s)
- A Gatopoulou
- Second Department of Internal Medicine, Democritus University of Thrace, Greece.
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Bielefeldt K. Gastroparesis: concepts, controversies, and challenges. SCIENTIFICA 2012; 2012:424802. [PMID: 24278691 PMCID: PMC3820446 DOI: 10.6064/2012/424802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/25/2012] [Indexed: 05/05/2023]
Abstract
Patients with gastroparesis often present a challenge to the treating physician. Postprandial symptoms with nausea and vomiting may not only lead to nutritional and metabolic consequences, but also cause significant disruptions to social activities that often center around food. While the definition of gastroparesis focuses on impaired gastric emptying, treatment options that affect gastric function are limited and often disappointing. The female predominance, the mostly idiopathic nature of the illness with a common history of abuse, and coexisting anxiety or depression show parallels with other functional disorders of the gastrointestinal tract. These parallels provided the rationale for some initial studies investigating alternative therapies that target the brain rather than the stomach. This emerging shift in medical therapy comes at a time when clinical studies suggest that gastric electrical stimulation may exert its effects by modulating visceral sensory processing rather than altering gastric motility. Physiologic and detailed anatomic investigations also support a more complex picture with different disease mechanisms, ranging from impaired accommodation to apparent visceral hypersensitivity or decreased interstitial cells of Cajal to inflammatory infiltration of myenteric ganglia. Delayed gastric emptying remains the endophenotype defining gastroparesis. However, our treatment options go beyond prokinetics and may allow us to improve the quality of life of affected individuals.
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Affiliation(s)
- Klaus Bielefeldt
- Division of Gastroenterology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
- *Klaus Bielefeldt:
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Li Z, Qi W, Geng YX, Pan DQ, Lu Y, Xu JZ, Wu WS. Effect of MWCNTs on Gastric Emptying in Mice. NANOSCALE RESEARCH LETTERS 2011; 6:63. [PMID: 27502684 PMCID: PMC3212210 DOI: 10.1007/s11671-010-9803-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 09/10/2010] [Indexed: 06/06/2023]
Abstract
After making model of gastric functional disorder (FD), part of model mice were injected intravenously (i.v.) with oxide multi-walled carbon nanotubes (oMWCNTs) to investigate effect of carbon nanotubes on gastric emptying. The results showed that NO content in stomach, compared with model group, was decreased significantly and close to normal level post-injection with oMWCNTs (500 and 800 μg/mouse). In contrast to FD or normal groups, the content of acetylcholine (Ach) in stomach was increased obviously in injection group with 500 or 800 μg/mouse of oMWCNTs. The kinetic curve of emptying was fitted to calculate gastric motility factor k; the results showed that the k of injection group was much higher than FD and normal. In other words, the gastric motility of FD mice was enhanced via injection with oMWCNTs. In certain dosage, oMWCNTs could improve gastric emptying and motility.
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Affiliation(s)
- Z Li
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China
| | - W Qi
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China
| | - Y X Geng
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China
| | - D Q Pan
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China
| | - Y Lu
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China
| | - J Z Xu
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China
| | - W S Wu
- Radiochemistry Laboratory, Lanzhou University, 73000, Lanzhou, People's Republic of China.
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Silva LF, Lopes GB, Matos CM, Brito KQ, Amoedo MK, Azevedo MF, Sá Araújo MJ, Martins MS, Lopes AA. Gastrointestinal symptoms and nutritional status in women and men on maintenance hemodialysis. J Ren Nutr 2011; 22:327-35. [PMID: 22071220 DOI: 10.1053/j.jrn.2011.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 07/18/2011] [Accepted: 07/19/2011] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The main objective was to investigate whether the prevalences of nausea, vomiting, diarrhea, and reduced appetite varied by gender in maintenance hemodialysis (MHD) patients. We also evaluated whether these symptoms explain female-male difference in nutritional status. DESIGN Cross section of baseline data of the Prospective Study of the Prognosis in Chronic Hemodialysis Patients. SETTING Dialysis units in the city of Salvador, Brazil. PATIENTS Three hundred ninety-seven men and 287 women with more than three months on MHD. PREDICTOR VARIABLE Gender. OUTCOME MEASURES The patient's self-reported nausea, vomiting, diarrhea, and reduced appetite. The malnutrition-inflammation score (MIS) was used to assess nutritional status. RESULTS The prevalence of symptoms was 24.3% for reduced appetite, 19.7% for nausea, 12.3% for vomiting, and 3.5% for diarrhea. In a logistic regression model with adjustments for age, diabetes, congestive heart failure, hemoglobin, albumin, Kt/V, and years on dialysis, women were found to have significantly higher odds of reduced appetite (odds ratio [OR] = 1.97), nausea (OR = 1.90), and vomiting (OR = 2.21). MIS was 5.41 ± 3.18 for women and 4.66 ± 3.28 for men (P = .002) corresponding to a percentage difference of 13.86%. The female-male difference reduced by more than half after excluding the gastrointestinal symptoms component and by approximately 65% after excluding both the gastrointestinal symptoms and the dietary intake components from the MIS. CONCLUSIONS The results suggest that the prevalences of nausea, vomiting, and reduced appetite are higher in women than in men on MHD. These gastrointestinal symptoms and perhaps their detrimental effects on dietary intake may partially explain a poorer nutritional status in MHD women.
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Affiliation(s)
- Luciana Ferreira Silva
- Núcleo de Epidemiologia Clínica, Hospital Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil
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Rostas JW, Mai TT, Richards WO. Gastric motility physiology and surgical intervention. Surg Clin North Am 2011; 91:983-99. [PMID: 21889025 DOI: 10.1016/j.suc.2011.06.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Disordered gastric motility represents a spectrum of dysfunction ranging from delayed gastric emptying to abnormally rapid gastric transit, commonly referred to as the "dumping syndrome." Both extremes of gastric motility disorders can arise from similar pathologic processes, and produce remarkably identical symptoms. This fact underscores the need to attain a precise diagnosis to ensure the institution of optimal therapy. Disordered gastric motility is primarily managed with dietary modification followed by pharmacotherapy, as traditional surgical interventions tend to be fraught with complications. However, continued improvements in minimally invasive diagnostic and therapeutic modalities promise novel options for earlier and more effective treatment.
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Affiliation(s)
- Jack W Rostas
- Department of Surgery, University of South Alabama College of Medicine, 2451 Fillingim Street, Mobile, AL 36617, USA
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Cellini J, Zaura Jukic AM, LePard KJ. Neostigmine-induced contraction and nitric oxide-induced relaxation of isolated ileum from STZ diabetic guinea pigs. Auton Neurosci 2011; 165:178-90. [PMID: 21880552 DOI: 10.1016/j.autneu.2011.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 07/14/2011] [Accepted: 07/27/2011] [Indexed: 02/06/2023]
Abstract
Both delayed gastrointestinal transit and autonomic neuropathy have been documented in patients with diabetes mellitus. The mechanism of neostigmine, an agent that mimics release of acetylcholine from autonomic neurons by prokinetic agents, to contract smooth muscle, despite dysfunctional enteric neural pathways, was determined using isolated ilea from STZ-treated and control guinea pigs. Both bethanechol- and neostigmine-induced contractions were stronger in diabetic ileum. Bethanechol-induced contractions of control but not diabetic ileum were increased by low dose scopolamine suggesting reduced activation of presynaptic muscarinic autoreceptors in diabetic ileum. The muscarinic receptor antagonist 4-DAMP strongly, but the nicotinic receptor antagonist hexamethonium only weakly, reduced neostigmine-induced contractions of control and diabetic ilea. The amount of acetylcholine, inferred from tissue choline content, was increased in diabetic ileum. Nicotinic neural and noncholinergic postjunctional smooth muscle receptors contributed more strongly to neostigmine-induced contractions in diabetic than control ileum. Relaxation of diabetic ileum by exogenous nitric oxide generated from sodium nitroprusside was comparable to control ileum, but smooth muscle relaxation by l-arginine using neuronal nitric oxide synthase to generate nitric oxide was weaker in diabetic ileum with evidence for a role for inducible nitric oxide synthase. Despite autonomic neuropathy, neostigmine strongly contracted ileum from diabetic animals but by a different mechanism including stronger activation of postjunctional muscarinic receptors, greater synaptic acetylcholine, stronger activation of noncholinergic excitatory pathways, and weaker activation of inhibitory pathways. A selective medication targeting a specific neural pathway may more effectively treat disordered gastrointestinal transit in patients with diabetes mellitus.
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Affiliation(s)
- Joseph Cellini
- Department of Physiology, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
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Keld R, Kinsey L, Athwal V, Lal S. Pathogenesis, investigation and dietary and medical management of gastroparesis. J Hum Nutr Diet 2011; 24:421-30. [DOI: 10.1111/j.1365-277x.2011.01190.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Farrugia G, Lurken MS, Bernard CE, Faussone-Pellegrini MS, Smyrk TC, Parkman HP, Abell TL, Snape WJ, Hasler WL, Ünalp-Arida A, Nguyen L, Koch KL, Calles J, Lee L, Tonascia J, Hamilton FA, Pasricha PJ. Cellular changes in diabetic and idiopathic gastroparesis. Gastroenterology 2011; 140:1575-85.e8. [PMID: 21300066 PMCID: PMC3081914 DOI: 10.1053/j.gastro.2011.01.046] [Citation(s) in RCA: 292] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 12/09/2010] [Accepted: 01/20/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Cellular changes associated with diabetic and idiopathic gastroparesis are not well described. The aim of this study was to describe histologic abnormalities in gastroparesis and compare findings in idiopathic versus diabetic gastroparesis. METHODS Full-thickness gastric body biopsy specimens were obtained from 40 patients with gastroparesis (20 diabetic) and matched controls. Sections were stained for H&E and trichrome and immunolabeled with antibodies against protein gene product (PGP) 9.5, neuronal nitric oxide synthase (nNOS), vasoactive intestinal peptide, substance P, and tyrosine hydroxylase to quantify nerves, S100β for glia, Kit for interstitial cells of Cajal (ICC), CD45 and CD68 for immune cells, and smoothelin for smooth muscle cells. Tissue was also examined by transmission electron microscopy. RESULTS Histologic abnormalities were found in 83% of patients. The most common defects were loss of ICC with remaining ICC showing injury, an abnormal immune infiltrate containing macrophages, and decreased nerve fibers. On light microscopy, no significant differences were found between diabetic and idiopathic gastroparesis with the exception of nNOS expression, which was decreased in more patients with idiopathic gastroparesis (40%) compared with diabetic patients (20%) by visual grading. On electron microscopy, a markedly increased connective tissue stroma was present in both disorders. CONCLUSIONS This study suggests that on full-thickness biopsy specimens, cellular abnormalities are found in the majority of patients with gastroparesis. The most common findings were loss of Kit expression, suggesting loss of ICC, and an increase in CD45 and CD68 immunoreactivity. These findings suggest that examination of tissue can lead to valuable insights into the pathophysiology of these disorders and offer hope that new therapeutic targets can be found.
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Kopelman Y, Triadafilopoulos G. Endoscopy in the diagnosis and management of motility disorders. Dig Dis Sci 2011; 56:635-54. [PMID: 21286936 DOI: 10.1007/s10620-011-1584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer). AIMS The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders. METHODS We performed a literature review in PubMed. RESULTS Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist. CONCLUSIONS This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.
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Affiliation(s)
- Yael Kopelman
- Stanford University School of Medicine, Stanford, CA, USA
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Abstract
Symptoms suggestive of gastroparesis occur in 5% to 12% of patients with diabetes. Such a complication can affect both prognosis and management of the diabetes; therefore, practicing clinicians are challenged by the complex management of such cases. Gastroparesis is a disorder characterized by a delay in gastric emptying after a meal in the absence of a mechanical gastric outlet obstruction. This article is an evidence-based overview of current management strategies for diabetic gastroparesis. The cardinal symptoms of diabetic gastroparesis are nausea and vomiting. Gastroesophageal scintiscanning at 15-minute intervals for 4 hours after food intake is considered the gold standard for measuring gastric emptying. Retention of more than 10% of the meal after 4 hours is considered an abnormal result, for which a multidisciplinary management approach is required. Treatment should be tailored according to the severity of gastroparesis, and 25% to 68% of symptoms are controlled by prokinetic agents. Commonly prescribed prokinetics include metoclopramide, domperidone, and erythromycin. In addition, gastric electrical stimulation has been shown to improve symptoms, reduce hospitalizations, reduce the need for nutritional support, and improve quality of life in several open-label studies.
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Affiliation(s)
- Badr M. Aljarallah
- Department of Medicine, Gastroenterology Division, King Fahad Specialist Hospital, Faculty of Medicine, Qassim University, Maledia, Saudi Arabia,Address for correspondence: Dr. Badr M. Aljarallah, Department of Medicine, Gastroenterology Division, King Fahad Specialist Hospital, Faculty of Medicine, Qassim University, Maledia - 51452, Saudi Arabia. E-mail:
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Cellini J, DiNovo K, Harlow J, LePard KJ. Regional differences in neostigmine-induced contraction and relaxation of stomach from diabetic guinea pig. Auton Neurosci 2010; 160:69-81. [PMID: 21075692 DOI: 10.1016/j.autneu.2010.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 09/27/2010] [Accepted: 10/07/2010] [Indexed: 12/19/2022]
Abstract
Delayed gastric emptying and autonomic neuropathy have been documented in patients with diabetes mellitus. Some medications used to treat delayed gastric emptying enhance release of acetylcholine from autonomic neurons to strengthen gastric contractions. Autonomic coordination among gastric regions may be altered in diabetes resulting in poor outcomes in response to prokinetic drugs. Fundus, antrum, and pylorus from STZ or control guinea pigs were treated with neostigmine to mimic release of acetylcholine from autonomic neurons by prokinetic agents. In diabetic animals, neostigmine-induced contractions were weaker in fundus and pylorus but similar in antrum. The muscarinic receptor antagonist 4-DAMP or the nicotinic receptor antagonist hexamethonium reduced neostigmine-induced contractions. Activation of presynaptic muscarinic receptors on nitrergic neurons was impaired in fundus and antrum from diabetic animals. Nerve-stimulated contractions and relaxations, number of nNOS myenteric neurons, and tissue choline content were reduced in fundus from diabetic animals. Despite reduced number of myenteric neurons, tissue choline content was increased in antrum from diabetic animals. Since cholinergic motility of each gastric region was affected differently by diabetes, prokinetic drugs that nondiscriminately enhance acetylcholine release from autonomic neurons may not effectively normalize delayed gastric emptying in patients with diabetes and more selective medications may be warranted.
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Affiliation(s)
- Joseph Cellini
- Department of Physiology, Chicago College of Osteopathic Medicine, Midwestern University, USA
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Gonzalez HC, Velanovich V. Enterra Therapy: gastric neurostimulator for gastroparesis. Expert Rev Med Devices 2010; 7:319-32. [PMID: 20420555 DOI: 10.1586/erd.10.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Gastroparesis is a chronic disorder of gastric motility characterized by delayed gastric empting in the absence of mechanical obstruction, which can lead to symptoms of nausea, vomiting, bloating, abdominal pain, postprandial fullness and weight loss. Although there are many etiologies, the primary causes are diabetes or are idiopathic. The mainstay of treatment is dietary and drug therapies. However, many patients will continue to suffer intractable symptoms despite these treatments. Gastric neurostimulation with the Enterra Therapy system has been approved for use under the Humanitarian Device Exemption by the US FDA. The device produces pulses of electrical stimulation that are delivered to the stomach continuously. One randomized clinical trial and multiple nonrandomized unblinded clinical trials and case series have documented improvement of symptoms in intractable diabetic and idiopathic gastroparesis. The purpose of this article is to introduce the Enterra Therapy gastric neurostimulator. Gastroparesis and its pathophysiology will be discussed in this clinical context to enhance the understanding of the device and its development. We will analyze the device in detail, its placement and the results of studies evaluating its efficacy.
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Abstract
Gastroparesis is a condition characterized by delayed gastric emptying and the most common known underlying cause is diabetes mellitus. Symptoms include nausea, vomiting, abdominal fullness, and early satiety, which impact to varying degrees on the patient's quality of life. Symptoms and deficits do not necessarily relate to each other, hence despite significant abnormalities in gastric emptying, some individuals have only minimal symptoms and, conversely, severe symptoms do not always relate to measures of gastric emptying. Prokinetic agents such as metoclopramide, domperidone, and erythromycin enhance gastric motility and have remained the mainstay of treatment for several decades, despite unwanted side effects and numerous drug interactions. Mechanical therapies such as endoscopic pyloric botulinum toxin injection, gastric electrical stimulation, and gastrostomy or jejunostomy are used in intractable diabetic gastroparesis (DG), refractory to prokinetic therapies. Mitemcinal and TZP-101 are novel investigational motilin receptor and ghrelin agonists, respectively, and show promise in the treatment of DG. The aim of this review is to provide an update on prokinetic and mechanical therapies in the treatment of DG.
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Affiliation(s)
- Uazman Alam
- Department of Cardiovascular Sciences, University of Manchester, Core Technology Facility (3rd Floor), Grafton Street, Manchester, M13 9NT UK
| | - Omar Asghar
- Department of Cardiovascular Sciences, University of Manchester, Core Technology Facility (3rd Floor), Grafton Street, Manchester, M13 9NT UK
| | - Rayaz Ahmed Malik
- Department of Cardiovascular Sciences, University of Manchester, Core Technology Facility (3rd Floor), Grafton Street, Manchester, M13 9NT UK
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Comorbid health conditions in women with syncope. Clin Auton Res 2010; 20:223-7. [PMID: 20458514 DOI: 10.1007/s10286-010-0070-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Accepted: 04/20/2010] [Indexed: 01/14/2023]
Abstract
OBJECTIVE We determine the comorbid conditions associated with syncope in women. In addition, we hypothesize a higher proportion of autonomic comorbid conditions during the female reproductive age. METHODS We identified a cohort of patients admitted to US hospitals with the principal diagnosis of syncope. We compare patient demographics stratified by gender as well as syncope associated comorbidities. We compared these comorbidities in female of reproductive age (15-45) to men as control. RESULTS From a total sample of 305,932, females constituted 56.7% (n = 173,434). Females were slightly older (mean age 70.9 +/- 17.9 vs. 66.7 +/- 17.3; P < 0.0001); with similar racial distribution (white 57.8 vs. 57.5%), and similar length of hospital stay (mean 2.66 +/- 2.63 vs. 2.68 +/- 2.72 days; P > 0.05). Females had higher proportion of migraine (1.65 vs. 1.29%; odds ratio 'OR' 1.29; 95% confidence interval 'CI' 1.21, 1.36); chronic fatigue syndrome (1.73 vs. 1.3%; OR 1.32; 95% CI 1.25, 1.4); gastroparesis (0.2 vs. 0.12%; OR 1.64; 95% CI 1.35, 1.98); interstitial cystitis (0.07 vs. 0.01%; OR 7.44; 95% CI 4.10, 13.5); and postural tachycardia syndrome (0.49 vs. 0.44%; OR 1.1; 95% CI 1.001, 1.23). Orthostatic hypotension was not different between the groups (P = 0.24). When the sample was stratified by age category, the odds ratio for gastroparesis, orthostatic hypotension, and postural tachycardia syndrome was increased (P < 0.05). INTERPRETATION A higher proportion of autonomic dysfunction was present in women compared to men. In addition, these comorbid autonomic conditions were especially prominent during the female reproductive age.
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Fraser H, Neshev E, Storr M, Urbanski SJ, Andrews CN. A novel method of full-thickness gastric biopsy via a percutaneous, endoscopically assisted, transenteric approach. Gastrointest Endosc 2010; 71:831-4. [PMID: 20363426 DOI: 10.1016/j.gie.2009.11.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 11/24/2009] [Indexed: 12/10/2022]
Abstract
BACKGROUND Pathologic changes of the enteric nervous system of the stomach have been described in gastroparesis. Because the enteric nervous system lies within the myenteric plexus between the muscle layers of the stomach, it is not accessible by standard biopsy forceps. Thus, tissue must be obtained by laparoscopy or laparotomy. Obtaining full-thickness biopsies with a less-invasive method would be an ideal alternative. OBJECTIVE To assess the safety and feasibility of a novel method of gastric, full-thickness biopsy by using a percutaneous, endoscopically assisted, transenteric approach. DESIGN Experimental pilot study in 3 dogs, approved by the animal care committee. INTERVENTION Under general anesthesia, dogs underwent gastroscopy, and a suitable biopsy area was chosen, based on indentation of the anterior stomach wall by external finger pressure on the abdominal skin and by endoscope transillumination. Using sterile technique, we made a 3-mm incision through the abdominal skin, and a spring-loaded, 14-gauge biopsy needle was used to take 4 separate antral biopsies from each dog, with no mucosal or abdominal closure intervention. MAIN OUTCOME MEASUREMENTS Feasibility of obtaining enteric nervous system tissue; morbidity and mortality at 4 weeks; gross pathology at necropsy. RESULTS The procedure was well tolerated by the dogs, with no morbidity or mortality at any time, up to 4 weeks after the procedure. Adequate tissue specimens were obtained for histologic analysis of all layers of the stomach, including enteric nervous system elements. LIMITATIONS Biopsy size was smaller than a surgical biopsy size. CONCLUSION The percutaneous, endoscopically assisted, transenteric approach, full-thickness biopsy technique is safe and obtains enteric nervous tissue in a simple, minimally invasive manner.
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Affiliation(s)
- Hughie Fraser
- Centre for Digestive Motility, Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
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Gastrointestinale Komplikationen nach kardiochirurgischen Operationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-009-0757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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