Effects of acute hyperglycaemia on anorectal motor and sensory function in diabetes mellitus

Rectal sensitivity correlated with gastrointestinal-mediated glucose disposal, but not the incretin effect

OBJECTIVE

The mechanisms behind the diminished incretin effect in type 2 diabetes are uncertain, but impaired vagal transmission has been suggested. We aimed to investigate the association between the incretin effect and autonomic neuropathy, and the degree of dysglycaemia and duration of diabetes.

DESIGN AND METHODS

For a cross-sectional study, we included participants with either longstanding type 2 diabetes, recent onset, untreated diabetes and controls without diabetes matched for age, sex and body mass index. Autonomic nerve function was assessed with cardiovascular reflex tests, heart rate variability and sudomotor function. Visceral afferent nerves in the gut were tested performing rapid rectal balloon distention. An oral glucose tolerance test and an intravenous isoglycaemic glucose infusion were performed to calculate the incretin effect and gastrointestinal-mediated glucose disposal (GIGD).

RESULTS

Sixty-five participants were recruited. Participants with diabetes had rectal hyposensitivity for earliest sensation (3.7 ± 1.1 kPa in longstanding, 4.0 ± 1.3 in early), compared to controls (3.0 ± 0.9 kPa), p = .005. Rectal hyposensitivity for earliest sensation was not associated with the incretin effect (rho = -0.204, p = .106), but an association was found with GIGD (rho -0.341, p = .005). Incretin effect and GIGD were correlated with all glucose values, HbA1c and duration of diabetes.

CONCLUSIONS

Rectal hyposensitivity was uncovered in both longstanding and early type 2 diabetes, and was not associated with the incretin effect, but with GIGD, implying a potential link between visceral neuropathy and gastrointestinal handling of glucose. Both the incretin effect and GIGD were associated with the degree of dysglycaemia and the duration of diabetes.

PREVIOUSLY PUBLISHED

Some of the data have previously been published and presented as a poster on the American Diabetes Association 83rd Scientific Sessions: Meling et al; 1658-P: Rectal Hyposensitivity, a Potential Marker of Enteric Autonomic Nerve Dysfunction, Is Significantly Associated with Gastrointestinally Mediated Glucose Disposal in Persons with Type 2 Diabetes. Diabetes 20 June 2023; 72 (Supplement_1): 1658-P. https://doi.org/10.2337/db23-1658-P.

The PanGut-study: Evoked potentials following rectal balloon distention, a way of evaluating diabetic autonomic neuropathy in the gut?

AIM

There is a lack of methods for investigating the autonomic nerves of the gastrointestinal tract. Our aim was to explore a novel test measuring visceral sensory evoked potentials (EPs) in response to rapid balloon distention in the rectum and compare it to established tests for diabetic neuropathy.

METHOD

Participants with longstanding type 2 diabetes, newly onset, untreated diabetes <1 year, and matched controls, were included. Tests included cardiovascular reflex tests, orthostatic blood pressure, electrical skin conductance assessment, sural nerve testing and monofilament test. The rectal balloon distention pressure at earliest sensation and threshold of unpleasantness were identified and used to elicit mechanical EPs.

RESULTS

The pressure at earliest sensation was higher in people with diabetes, 0.038 (0.012) bar vs. controls 0.030 (0.009) bar, p = 0.002, and in people with signs of peripheral neuropathy, 0.045 (0.014) bar, p < 0.01. Clinical correlations between EP amplitude and latency, and other tests were found.

CONCLUSIONS

Rectal hyposensitivity was associated with both longstanding and early diabetes, indicating enteric sensory dysfunction already in early stages of diabetes. Correlation analyses may indicate that central afferent processing is affected in parallel with peripheral neuronal function.

Effect of gender on the etiology of fecal incontinence: Retrospective analysis of a tertiary referral center in Turkey

BACKGROUND/AIMS

Anorectal diseases, including fecal incontinence, are prevalent and have an enormous impact on the quality of life. Therefore, investigating their etiological factors may help to reduce the incidence and/or the severity of the underlying diseases.

MATERIALS AND METHODS

Referral complaints (constipation, strained defecation, and incontinence) and medical and anorectal manometry records of 883 (562 female/321 male, ages 45.17±1.00 and 48.41±0.63 years, respectively) patients were evaluated retrospectively. Maximal resting pressure (MRP) and maximal squeeze pressure (MSP) measured by stationary pull-through technique, volume of rectoanal inhibitory reflex, and sensory threshold to rectal balloon distention (ST) were obtained by water perfusion system. Data were compared according to referral complaints, age, gender, parity, and underlying diseases.

RESULTS

Incontinence was the most frequent referral complaint in 61.2% of females and 67.6% of males. MRP and MSP were significantly lower in incontinent females than in the other groups. In incontinent males, MSP was lower than the strained defecation group, and ST was higher than the constipation group. Age was negatively correlated with MRP for both of the genders and in all groups. Obstetric trauma (85%) and number of parity (3.40±2.59) were significantly higher in incontinent females. Moreover, the most prevalent underlying disease was diabetes in incontinent females (13.7%) and neurological diseases, including traumas, in incontinent males (41.5%).

CONCLUSION

Increasing awareness of labor safety, controlling diabetes mellitus, and preventing obstetric traumas may reduce the prevalence of fecal incontinence.

Pathophysiology and management of diabetic gastroenteropathy

Polyneuropathy is a common complication to diabetes. Neuropathies within the enteric nervous system are associated with gastroenteropathy and marked symptoms that severely reduce quality of life. Symptoms are pleomorphic but include nausea, vomiting, dysphagia, dyspepsia, pain, bloating, diarrhoea, constipation and faecal incontinence. The aims of this review are fourfold. First, to provide a summary of the pathophysiology underlying diabetic gastroenteropathy. Secondly to give an overview of the diagnostic methods. Thirdly, to provide clinicians with a focussed overview of current and future methods for pharmacological and nonpharmacological treatment modalities. Pharmacological management is categorised according to symptoms arising from the upper or lower gut as well as sensory dysfunctions. Dietary management is central to improvement of symptoms and is discussed in detail, and neuromodulatory treatment modalities and other emerging management strategies for diabetic gastroenteropathy are discussed. Finally, we propose a diagnostic/investigation algorithm that can be used to support multidisciplinary management.

Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey

BACKGROUND & AIMS

Fecal incontinence (FI) is characterized by uncontrolled passage of solid or liquid stool. We aimed to determine the prevalence and severity of FI in a large sample of US residents.

METHODS

We recruited a representative sample of patients in October 2015 to complete the National Gastrointestinal (GI) Survey; a mobile app called MyGiHealth was used to systematically collect data on GI symptoms. FI was defined as accidental leakage of solid or liquid stool. Severity of FI was determined by responses to the National Institutes of Health FI Patient Reported Outcomes Measurement Information System questionnaire. Multivariable regression models were used to identify factors associated with FI prevalence and severity.

RESULTS

Among 71,812 individuals who completed the National GI Survey, 14.4% reported FI in the past; of these, 33.3% had FI within the past 7 days. Older age, male sex, and Hispanic ethnicity increased the likelihood of having FI within the past week. Individuals with Crohn's disease, ulcerative colitis, celiac disease, irritable bowel syndrome, or diabetes were more likely to report FI. Non-Hispanic black and Hispanic individuals and individuals with Crohn's disease, celiac disease, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, or chronic idiopathic constipation had more severe symptoms of FI than individuals without these features.

CONCLUSIONS

In a large population-based survey, 1 in 7 people reported previous FI. FI is age-related and more prevalent among individuals with inflammatory bowel disease, celiac disease, irritable bowel syndrome, or diabetes than people without these disorders. Proactive screening for FI among these groups is warranted.

Gastrointestinal Symptoms in Diabetes: Prevalence, Assessment, Pathogenesis, and Management

If you haven't measured something, you really don't know much about it.-Karl Pearson (attributed)Gastrointestinal (GI) symptoms represent an important and often unappreciated cause of morbidity in diabetes, although the significance of this burden across the spectrum of patients and the underlying pathophysiology, including the relationship of symptoms with glycemic control, remain poorly defined. The relevance of GI symptoms and the necessity for their accurate assessment have increased with the greater focus on the gut as a therapeutic target for glucose lowering. This review addresses the prevalence, assessment, pathogenesis, and management of GI symptoms in diabetes, beginning with broad principles and then focusing on specific segments of the GI tract. We initially performed a literature search of PubMed by using synonyms and combinations of the following search terms: "gastrointestinal symptoms", "diabetes", "prevalence", "pathogenesis", "diagnosis", and "management". We restricted the search results to English only. Review papers and meta-analyses are presented as the highest level of evidence where possible followed by randomized controlled trials, uncontrolled trials, retrospective and observational data, and expert opinion.

A Practical Approach to Gastrointestinal Complications of Diabetes

Gastrointestinal symptoms occur frequently among people with diabetes mellitus and are associated with considerable morbidity. Enteropathy, or large bowel dysfunction, includes constipation, diarrhea and fecal incontinence, and is particularly disturbing for many patients. The pathogenesis of diabetic enteropathy is complex, primarily related to gastrointestinal autonomic dysfunction and etiologically associated with chronic hyperglycemia and diabetes duration. Since there are many other non-iatrogenic and iatrogenic causes of the cardinal symptoms of large bowel dysfunction, patients suspected of having diabetic enteropathy require detailed evaluation. The management of patients with diabetic enteropathy is challenging, and often requires a multidisciplinary approach focusing on a combination of symptom mitigation and glycemic control.

Gut symptoms in diabetics correlate with components of the rectoanal inhibitory reflex, but not with pudendal nerve motor latencies or systemic autonomic neuropathy

OBJECTIVE

Fecal incontinence (FI) occurs in up to 20% of diabetes mellitus (DM) patients. Rectoanal inhibitory reflex (RAIR) is an enteric anorectal reflex that reflects the integrity of mechanisms in the physiology of FI. We aimed to investigate whether diabetic patients with FI, not constipation, had prolongation of RAIR and altered gut-specific autonomic tone.

METHODS

In this prospective case-matched study 31 type I DM (19 FI and 12 constipation) and 42 type II DM (26 FI and 16 constipation). Another 21 participants were included as controls. Patients underwent the following assessments: cardiovagal autonomic tone (Modified Mayo Clinic composite autonomic severity score), rectal mucosal blood flow (RMBF) (assessment of gut-specific autonomic tone) and RAIR. Three phases of RAIR and the amplitude of maximal reflex relaxation were compared between groups. All participants completed symptom scores for FI and constipation.

RESULTS

RAIR recovery time back to resting pressure was slower in diabetic patients with FI than controls (8.7 s vs 3.6 s, P < 0.05) and was an independent variable correlating with symptoms of FI (P < 0.05). RAIR recovery time was correlated with RMBF (r = 0.58, P = 0.04).

CONCLUSION

RAIR is correlated with anorectal symptoms of FI and was associated with gut-specific autonomic neuropathy.

Rectal sensitivity in diabetes patients with symptoms of gastroparesis

In a clinical setting, diabetic autonomic complications (cardiac, gastrointestinal, urogenital, etc.) are often handled as separate entities. We investigated rectal sensitivity to heat, mechanical distension, and electrical stimulations in 20 patients with diabetes and symptoms of gastroparesis, to evaluate the extent of visceral neuronal damage. Furthermore, to evaluate the relation between the nervous structures we examined gastric emptying and cardiac autonomic function with the hypothesis being an association between these. We found that 60% of patients had delayed gastric empting. Rectal hyposensitivity was a general finding as they tolerated 67% higher thermal, 42% more mechanical, and 33% higher electrical current intensity compared to healthy controls. In patients, most heart rate variability parameters were reduced; they reported significantly more gastrointestinal symptoms and a reduced quality of life in all SF-36 domains. Shortened RR interval correlated with reduced rectal temperature sensitivity, and gastric retention rate was negatively associated with symptoms of nausea and vomiting. To conclude, in these patients with signs and symptoms of diabetic gastroparesis, rectal sensitivity was reduced, and heart rate variability was impaired. Thus, we suggest regarding diabetic autonomic neuropathy as a diffuse disorder. Symptoms of widespread autonomic dysfunction and sensory disorders should be expected and treated in these patients.

Gastrointestinal complications of diabetes

This review provides an overview of the vast gastrointestinal tract complications of diabetes that can occur from the mouth to the anus. The presentation, diagnosis, and management of gastrointestinal disorders, ranging from gastroparesis, celiac disease, and bacterial overgrowth to nonalcoholic fatty liver disease, are reviewed to heighten awareness. When managing care of patients with diabetes, one should keep in mind the potential gastrointestinal complications, as well as the frequent disorders that are not related to diabetes.

Diabetic gastrointestinal autonomic neuropathy: current status and new achievements for everyday clinical practice

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.

Prevalência da incontinência anal na população urbana de Pouso Alegre - Minas Gerais

Os objetivos deste estudo foram conhecer a prevalência da incontinência anal (IA) em adultos da cidade de Pouso Alegre (Minas Gerais) e verificar os fatores demográficos e clínicos preditores de sua presença. Estudo epidemiológico desenvolvido por meio de amostragem estratificada por conglomerado, tendo amostra final composta de 519 indivíduos, com idade >18 anos, em condições físicas e mentais adequadas, residentes em 341 domicílios da área urbana e sorteados aleatoriamente. As prevalências foram padronizadas por sexo e idade, resultando em 7,0% para IA, tanto geral como para homens e mulheres. No modelo final de regressão logística, número de filhos (OR=5,1; p<0,001), doença hemorroidária (OR=4,4; p<0,001) e cistocele (OR=3,0; p<0,001) estavam associados à presença de IA. O estudo permitiu conhecer a epidemiologia da IA e pode contribuir para o desenvolvimento de políticas públicas visando à prevenção primária e secundária, e ao tratamento, ainda que inicialmente em nível municipal.

Effect of acute hyperglycaemia on sensory processing in diabetic autonomic neuropathy

BACKGROUND

Acute hyperglycaemia is known to increase gastrointestinal (GI) sensitivity in healthy subjects and may contribute to the increased prevalence of GI symptoms in diabetes patients. The aim of this study was to evaluate the effect of acute hyperglycaemia on perception and brain responses to painful visceral and somatic stimuli in diabetic patients.

MATERIALS AND METHODS

The sensitivity and evoked brain potentials (EPs) to electrical oesophageal and median nerve stimulations were assessed in 14 type-1 diabetes patients with autonomic neuropathy and GI symptoms using a hyperinsulinaemic clamp at 6 and 15 mM.

RESULTS

No differences between the normo- and hyperglycaemic conditions were found in sensitivity to both oesophageal (P=0·72) and median nerve (P=0·66) stimulations. The latencies and amplitudes of EPs did not differ between the normo- and hyperglycaemic conditions following oesophageal (P=0·53 and 0·57) and median nerve (P=0·78 and 0·52) stimulations.

CONCLUSIONS

Acute hyperglycaemia itself does not contribute to the sensations in patients with longstanding diabetes and autonomic neuropathy. Any potential sensory effects of acute hyperglycaemia can likely be blurred by the neuropathic-like changes in the sensory nervous system.

Diabetic diarrhea

Diabetic patients with diarrhea may present clinical challenges in diagnosis and treatment. Particular diagnoses are more prevalent in diabetic patients than in the general population. Medications are often a culprit for chronic diarrhea, and the medication list should always be carefully scrutinized for those with diarrhea as a side effect. In diabetic patients, metformin is a common cause of diarrhea. Diabetic patients are more likely to have associated diseases (eg, celiac sprue and microscopic colitis) that present with diarrhea as the sole complaint. Ingested sugar-free foods that may contain sorbitol or other agents can cause diarrhea in diabetic patients. Finally, diabetic enteropathy can itself cause diarrhea. The various etiologies can be diagnosed with a thorough history and appropriate diagnostic tests. This article focuses on the etiologies of diarrhea that are seen with higher incidence in diabetic patients.

Faecal incontinence in older people

Faecal incontinence in older people is a distressing and socially isolating symptom and increases the risk of morbidity, mortality and dependency. Many older individuals with faecal incontinence will not volunteer the problem to their general practitioner or nurse and, regrettably, health care providers do not routinely enquire about the symptom. Even when older people are noted by health care professionals to have faecal incontinence, the condition is often managed passively, especially in the long-term care setting where it is most prevalent. The importance of identifying treatable causes of faecal incontinence in older people, rather than just managing passively, is strongly emphasized in national and international guidance, but audit shows that adherence to such guidance is generally poor. This article describes epidemiology, causes, assessment, diagnosis and treatment of faecal incontinence in older people.

Gastrointestinal symptoms and glycemic control in diabetes mellitus: a longitudinal population study

BACKGROUND

The prevalence of gastrointestinal (GI) symptoms is increased in diabetes, but their natural history is understood poorly and any impact of glycemic control is controversial. We aimed to quantify changes in GI symptom status and glycemic control among a population sample of patients with diabetes.

METHODS

Data on 10 chronic GI symptom complexes were obtained from a validated questionnaire at baseline and after 12 months. Changes in acute and chronic glycemic control were classified as always adequate, variable (deteriorated or improved), or always inadequate; acute glycemic control was assessed by fasting plasma glucose and chronic glycemic control by a validated self-report 5-point graded scale.

RESULTS

Baseline and follow-up data were available in 136 individuals with diabetes (mean age 59 years; 66% males; 95% type 2). The most prevalent GI symptom complexes were abdominal bloating/distension (35%), ulcer-like dyspepsia (35%), and irritable bowel syndrome (27%). Overall, between 7 and 24% reported a change in GI symptoms with the largest change in irritable bowel syndrome (24%), bloating/distension (22%), and ulcer-like dyspepsia (21%). Those who had a change in abdominal bloating (either loss or gain) over 12 months were more likely to have increased their mean fasting plasma glucose (P<0.05). Contrary to expectations, consistently poor self-reported glycemic control was only weakly associated with less persistent abdominal pain (r=-0.2, P=0.03), diarrhea (r=-0.22, P=0.01), and abdominal bloating (r=-0.2, P=0.03). Acute glycemic control was not significantly related to any GI symptoms.

CONCLUSION

We were unable to demonstrate any association between worsening GI symptoms and glycemic control.

Effect of duodenal glucose and acute hyperglycemia on rectal perception and compliance in response to tension-controlled rectal distension in healthy humans

BACKGROUND

Acute changes in blood glucose concentration affect gastrointestinal motor and sensory function. Tone and distensibility contribute to intact rectal function.

AIMS

To test the effects of duodenal glucose (euglycemic hyperinsulinemia), intravenous glucose (hyperglycemic hyperinsulinemia), and saline (euglycemic normoinsulinemia as control) on rectal perception and compliance in response to tension-controlled rectal distension.

METHODS

During duodenal glucose at 2 kcal min(-1), marked hyperglycemic clamp (approximately 13 mmol L(-1)), or saline as control, responses to fixed-tension rectal distension, applied by means of a computerized tensostat, were compared randomized on three separate days in eight healthy subjects.

RESULTS

At discomfort level (score 3 on the 0-4 rectal score scale), perception of rectal distension was significantly higher during euglycemic hyperinsulinemia (45 +/- 3 g cm(-2) tolerance) and significantly lower during hyperglycemia (83 +/- 4 g cm(-2) tolerance), both reaching significance versus control (64 +/- 6 g cm(-2) tolerance; P < 0.05). At this level, no relevant variations of rectal compliance were seen, which were 10.3 +/- 1 mL mmHg(-1) during duodenal glucose, 9.5 +/- 1 mL mmHg(-1) for the group with hyperglycemia, and 9.7 +/- 2 mL mmHg(-1) for the control.

CONCLUSION

Duodenal glucose provokes rectal hypersensitivity whereas acute hyperglycemia contributes to rectal hyposensitivity. Despite different rectal tenso-sensitivity, rectal compliance remains virtually unchanged. Any dysfunction may cause rectal complaints.

Therapy Insight: gastrointestinal complications of diabetes--pathophysiology and management

Patients with diabetes often have gastrointestinal symptoms, but the extent and severity of this problem and the specificity of the symptoms are not nearly as well defined as frequently assumed. Any part of the gastrointestinal tract can be affected, and the presenting symptoms depend on the composite of dysfunctional elements. Gastroesophageal reflux, Candida esophagitis, gastroparesis, diarrhea and constipation are among the many common gastrointestinal complications of diabetes. No specific risk factor for the development of these complications has been identified and their etiology is most likely to be multifactorial, involving both reversible and irreversible processes. Treatment should be directed at tighter glycemic and symptom control, which can bring about clinical improvement for many patients. For other patients, however, effective clinical management is problematic because no therapies are available to prevent or correct the underlying disease mechanisms. Studies now suggest that reduced levels of key trophic factors cause transdifferentiation of pacemaker interstitial cells of Cajal into a smooth-muscle-like phenotype. If this really is the case, therapies directed at restoring the normal milieu of trophic signals could correct the dysfunction of the interstitial cells of Cajal and resolve many gastrointestinal complications. Advances in stem cell technology also hold promise to provide a cure for diabetes and to correct abnormalities in gastrointestinal pathology.

Fecal incontinence in females older than aged 40 years: who is at risk?

PURPOSE

This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years.

METHODS

The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,109 randomly selected middle-aged and older females (average age, 56 years). Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year.

RESULTS

Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form-36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m2 (95 percent confidence interval)] with obesity [1.2 (1.1-1.3)], chronic obstructive pulmonary disease [1.9 (1.3-2.9)], irritable bowel syndrome [2.4 (1.7-3.4)], urinary incontinence [2.1 (1.7-2.6)], and colectomy [1.9 (1.1-3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4-0.9)].

CONCLUSIONS

Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.