Effects of cisapride on gall bladder emptying, intestinal transit, and serum deoxycholate: a prospective, randomised, double blind, placebo controlled trial

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Therapeutic potential of serotonin 4 receptor for chronic depression and its associated comorbidity in the gut

The latest estimates from world health organization suggest that more than 450 million people are suffering from depression and other psychiatric conditions. Of these, 50-60% have been reported to have progression of gut diseases. In the last two decades, researchers introduced incipient physiological roles for serotonin (5-HT) receptors (5-HTRs), suggesting their importance as a potential pharmacological target in various psychiatric and gut diseases. A growing body of evidence suggests that 5-HT systems affect the brain-gut axis in depressive patients, which leads to gut comorbidity. Recently, preclinical trials of 5-HT4R agonists and antagonists were promising as antipsychotic and prokinetic agents. In the current review, we address the possible pharmacological role and contribution of 5-HT4R in the pathophysiology of chronic depression and associated gut abnormalities. Physiologically, during depression episodes, centers of the sympathetic and parasympathetic nervous system couple together with neuroendocrine systems to alter the function of hypothalamic-pituitary-adrenal (HPA) axis and enteric nervous system (ENS), which in turn leads to onset of gastrointestinal tract (GIT) disorders. Consecutively, the ENS governs a broad spectrum of physiological activities of gut, such as visceral pain and motility. During the stages of emotional stress, hyperactivity of the HPA axis alters the ENS response to physiological and noxious stimuli. Consecutively, stress-induced flare, swelling, hyperalgesia and altered reflexes in gut eventually lead to GIT disorders. In summary, the current review provides prospective information about the role and mechanism of 5-HT4R-based therapeutics for the treatment of depressive disorder and possible consequences for the gut via brain-gut axis interactions. This article is part of the special issue entitled 'Serotonin Research: Crossing Scales and Boundaries'.

Augmented cholesterol absorption and sarcolemmal sterol enrichment slow small intestinal transit in mice, contributing to cholesterol cholelithogenesis

Cholesterol gallstones are associated with slow intestinal transit in humans as well as in animal models, but the molecular mechanism is unknown. We investigated in C57L/J mice whether the components of a lithogenic diet (LD; 1.0% cholesterol, 0.5% cholic acid and 17% triglycerides), as well as distal intestinal infection with Helicobacter hepaticus, influence small intestinal transit time. By quantifying the distribution of 3H-sitostanol along the length of the small intestine following intraduodenal instillation,we observed that, in both sexes, the geometric centre (dimensionless) was retarded significantly (P <0.05) by LD but not slowed further by helicobacter infection (males, 9.4±0.5 (uninfected), 9.6±0.5 (infected) on LD compared with 12.5±0.4 and 11.4±0.5 on chow). The effect of the LD was reproduced only by the binary combination of cholesterol and cholic acid. We inferred that the LD-induced cholesterol enrichment of the sarcolemmae of intestinal smooth muscle cells produced hypomotility from signal-transduction decoupling of cholecystokinin (CCK), a physiological agonist for small intestinal propulsion in mice. Treatment with ezetimibe in an amount sufficient to block intestinal cholesterol absorption caused small intestinal transit time to return to normal. In most cholesterol gallstone-prone humans, lithogenic bile carries large quantities of hepatic cholesterol into the upper small intestine continuously, thereby reproducing this dietary effect in mice. Intestinal hypomotility promotes cholelithogenesis by augmenting formation of deoxycholate, a pro-lithogenic secondary bile salt, and increasing the fraction of intestinal cholesterol absorbed.

Cisapride for intestinal constipation

BACKGROUND

Cisapride is a propulsive agent, withdrawn from most of the world's health institutes because of its recorded fatalities in addition to serious side effects such as severe arrhythmias. However it is widely available in third world countries and can be easily purchased through the Internet.  We did a systematic review to assess its efficacy and safety in relieving constipation.

OBJECTIVES

The primary objective is to assess Cisapride's role and safety as a prokinetic drug in the management of constipation and constipation predominant Irritable bowel syndrome (C-IBS).The secondary objective is to assess Cisapride's efficacy in improving symptoms of constipation and IBS.

SEARCH STRATEGY

Cochrane methodology was followed to find available RCTs that assessed the efficacy of cisapride. Electronic databases searched November 2009:Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library 2009 issue 4MEDLINE (from 1966)EMBASE (from 1980)

SELECTION CRITERIA

All RCTs comparing cisapride to placebo or to active comparators were included. We included patients of all ages who had functional constipation or C-IBS.

DATA COLLECTION AND ANALYSIS

Eight RCTs were included, comparing cisapride to a placebo on patients with constipation or C-IBS. The studies were pooled and analysed and a combined effect was calculated using meta-analysis.

MAIN RESULTS

8 trials included in the review for a total 424 patients who were randomised to Cisapride or placebo, of which 157 were children and 284 were female. Intervention duration was 8 to 12 weeks. Dosage of Cisapride in the adult and children trials were 5mg TDS and 0.2mg/kg/dose TDS respectively.Cisapride showed significant benefit in investigators' assessment of clinical improvement (OR: 0.45, P=0.03), likelihood of passing daily stools (OR: 0.22, P<0.001), passage of normal stools (OR: 0.06, P<0.001) and total gastrointestinal transit time (MD: -19.47, P<0.00001). However Cisapride showed no benefit in global improvement of symptoms (MD: 0.11, P=0.99), abdominal pain (MD: 1.94, P=0.56), stool frequency: weekly (MD: 3.36, P=0.11), visual analogue scale (MD: -0.23, P=0.66), stool consistency (MD: 0.32, P=0.50), bloating (MD: 3.93, P=0.44), persistent bloating(OR: 1.11, P=0.83), 'feeling of incomplete evacuation' (MD: -3.80, P=0.08), straining (MD -0.95, p=0.19).

AUTHORS' CONCLUSIONS

No clear benefit can be demonstrated with cisapride. We do not feel that cisapride can be justifiably used for chronic constipation or irritable bowel disease given its side effects of arrhythmia and associated 175 recorded deaths.

Diabetic gastroparesis: diagnosis and management

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

Effectiveness of prokinetic agents against diseases external to the gastrointestinal tract

Prokinetic agents are effective not only for disease of the gastrointestinal (GI) tract but also for those external to the GI tract such as the central nervous system, and the respiratory, urologic, and metabolic organs. This article reviews the effectiveness of prokinetic agents against diseases external to the GI tract. Studies were identified by computerized and manual searches of the available literature. A Medline search was performed (1975-July, 2008) using the following medical subject headings: prokinetic agent, metoclopramide, domperidone, trimebutine, cisapride, itopride, mosapride, tegaserod, and human. The identified diseases for which prokinetic agents may be effective are various: bronchial asthma, chronic cough, hiccup, spontaneous bacterial peritonitis, cholelithiasis, diabetes mellitus, acute migraine, Parkinson's disease, anorexia nervosa, Tourette's disorder, urologic sequelae of spinal cord injury and of radical hysterectomy for cervical cancer, laryngeal dysfunction and so on. These agents are also useful for prevention of aspiration pneumonia during anesthesia, and in tube-fed patients. Prokinetic agents should be a valuable addition to our currently limited pharmacological armamentarium not only for functional bowel disease, but also for diseases external to the GI tract.

Diagnostic and therapeutic approach to pancreatic cancer-associated gastroparesis: literature review and our experience

BACKGROUND

Patients with unresectable pancreatic carcinoma often present with early satiety, nausea, and vomiting without evidence of mechanical obstruction, mucosal disease, or metabolic abnormality. This condition is well described in the literature and is thought to result from pancreatic cancer-associated gastroparesis (PCAG). No clinical guideline is available for diagnosing and managing this rare disease.

OBJECTIVE

To propose an algorithm for diagnosing and managing patients with PCAG based on a literature review and our clinical experience.

METHODS

A comprehensive review was conducted of literature on the subject from 1966 to 2005, and retrospective analysis was performed for patients with PCAG who presented to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) during the period 1998-2005.

RESULTS

Literature on an optimal diagnostic and therapeutic approach to PCAG is lacking. There are only two small case series and one case report regarding management of PCAG. Extensive chart review only identified two patients who met the diagnostic criteria of PCAG. We propose performing routine upper GI series and esophagogastroduodenoscopy on all patients with pancreatic cancer who present with nausea and vomiting, to rule out obstruction and mucosal disease. If there is no obstruction or mucosal disease, we do not recommend further workup. Prokinetic agents are the first line therapy for PCAG. In refractory cases, percutaneous endoscopic gastrostomy with jejunal extension may be considered in selected patients who respond to nasojejunal decompression.

CONCLUSIONS

We propose a time-effective and useful strategy for diagnosing and managing patients with PCAG. We also define the diagnostic end-point for this difficult to manage condition.

Withdrawal of somatostatin analogue therapy in patients with acromegaly is associated with an increased risk of acute biliary problems

BACKGROUND

The prevalence of gallstones (GS) is increased in acromegaly and further increased by somatostatin analogue (SA) therapy. The incidence is reported at 10-63%, but they are often asymptomatic and rarely require definitive management. Evidence suggests discontinuation of SA may precipitate acute biliary problems.

OBJECTIVE

To determine the frequency of symptomatic gallstones in patients treated with SA.

DESIGN

Retrospective analysis of prospectively followed patients in our centre.

RESULTS

Fifty patients (30 male, mean age 54 +/- 16 years) were on treatment with SA on 1 January 2003. Fifteen (11 male, mean age 50 +/- 17 years) have since discontinued SA with three proceeding to develop acute cholecystitis and two, biliary colic necessitating cholecystectomy. Three of the five had abnormal liver enzymes at or within 3 months of symptomatic presentation. Two of the remaining 35 patients experienced biliary colic necessitating cholecystectomy. These data indicate a highly significant increase in acute biliary problems on discontinuing SA (5 in 27.67 patient 'off-treatment' years vs. 2 in 299 patient treatment years, chi(2), P < 0.0001). All seven patients experiencing problems were male (P = 0.01).

CONCLUSION

This analysis demonstrates the high incidence of symptomatic GS following SA withdrawal, particularly in men. Although liver enzymes were raised no common abnormality was evident to aid as a predictor of future symptoms. We recommend all patients due to stop SA be forewarned of the risk of acute biliary problems. Further work is required to confirm if there is a gender-related difference in the incidence of acute biliary problems on discontinuing SA therapy.

Pathophysiology and management of diabetic gastropathy: a guide for endocrinologists

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

New management approaches for gastroparesis

Management of patients with gastroparesis is challenging. Although the syndrome has multiple causes and knowledge of the pathophysiology and natural history is far from complete, a number of common management principles can be applied. The relatively poor correlation between upper-gastrointestinal symptoms and disordered gastric emptying represents a major difficulty in the therapeutic approach, and evidence to support the efficacy of current management strategies is often suboptimal, especially in relation to long-term therapy. In this review, the common causes and pathophysiology of gastroparesis are summarized, the diagnostic approach considered, and the evidence to support medical and surgical therapies reviewed. These therapies include currently available prokinetic drugs, novel medical therapies, and the promising technique of gastric electrical stimulation.

Idiopathic and Diabetic Gastroparesis

The management of both diabetic and idiopathic gastroparesis often represents a substantial clinical challenge. In formulating recommendations for therapy, it should be recognized that these are based on less than optimal evidence; in particular, there are substantial deficiencies in current knowledge relating to the pathophysiology of gastroparesis, as well as the natural history of gastrointestinal symptoms, and the majority of pharmacologic trials have been short term and associated with methodologic limitations. Although the etiologic factors differ, the overall management principles are similar in the two conditions. Maintenance of adequate nutrition is pivotal, and parenteral nutrition may be required in severe cases associated with malnutrition. In patients with diabetes, rigorous attempts should be made to optimize glycemic control--hyperglycemia slows gastric emptying and may exacerbate symptoms and attenuate the effects of prokinetic drugs. Despite the relatively poor predictive value of symptoms, it is reasonable to suggest a trial of prokinetic therapy for about 4 weeks, rather than initially establishing the diagnosis by measurement of gastric emptying. However, it should be recognized that there is a substantial placebo response, a lack of evidence to support the cost effectiveness of such an approach, and that most patients will require prolonged therapy. In type 1 diabetic patients, prokinetic therapy may potentially benefit glycemic control, and this forms an additional rationale (albeit not established) for therapy. Some patients with diabetes and idiopathic gastroparesis with severe vomiting are unable to tolerate oral medication; in such cases subcutaneous metoclopramide may prove useful. Patients with intractable symptoms should be hospitalized and given intravenous erythromycin. The repertoire of prokinetic agents available in the United States is limited and includes metoclopramide, erythromycin, and cisapride (available by special program from its manufacturer); all of these drugs are associated with side effects. The use of metoclopramide may represent the first choice for chronic oral therapy, although it has been studied less comprehensively than cisapride. Combination therapy may be potentially more efficacious than the use of single agents. Dehydration and metabolic derangements should be corrected. The choice of chronic medical therapy should be individualized, taking factors such as age, presence of diabetes, concurrent medications, and comorbidities into account. In a small number of patients in whom medical treatment fails, surgery should be considered, and, if performed, done in a specialized center. A number of novel therapies, including gastric electrical stimulation, are currently being evaluated.

Intestinal aspects of cholesterol gallstone formation

Apart from biliary cholesterol supersaturation, crystallization-promoting proteins and impaired postprandial gallbladder motility, the intestine may be an important factor in the pathogenesis of cholesterol gallstones. Prolonged intestinal transit could increase gallstone risk by enhancing formation in the intestinal lumen of the secondary hydrophobic and pro-lithogenic bile salt deoxycholate. Furthermore, in normal subjects there is an intimate relationship between gallbladder and intestinal motility in the fasting (interdigestive) state. In gallstone patients we found disordered intestinal motility, absent gallbladder contraction and abnormal release of the hormone motilin in the interdigestive state. These disturbances could contribute to gallstone formation.

Bile acid metabolism by fresh human colonic contents: a comparison of caecal versus faecal samples

BACKGROUND

Deoxycholic acid (DCA), implicated in the pathogenesis of gall stones and colorectal cancer, is mainly formed by bacterial deconjugation (cholylglycine hydrolase (CGH)) and 7 alpha-dehydroxylation (7 alpha-dehydroxylase (7 alpha-DH)) of conjugated cholic acid (CA) in the caecum/proximal colon. Despite this, most previous studies of CGH and 7 alpha-DH have been in faeces rather than in caecal contents. In bacteria, CA increases 7 alpha-DH activity by substrate-enzyme induction but little is known about CA concentrations or CA/7 alpha-DH induction in the human colon.

AIMS AND METHODS

Therefore, in fresh "faeces", and in caecal aspirates obtained during colonoscopy from 20 patients, we: (i) compared the activities of CGH and 7 alpha-DH, (ii) measured 7 alpha-DH in patients with "low" and "high" percentages of DCA in fasting serum (less than and greater than the median), (iii) studied CA concentrations in the right and left halves of the colon, and examined the relationships between (iv) 7 alpha-DH activity and CA concentration in caecal samples (evidence of substrate-enzyme induction), and (v) 7 alpha-DH and per cent DCA in serum.

RESULTS

Although mean CGH activity in the proximal colon (18.3 (SEM 4.40) x10(-2) U/mg protein) was comparable with that in "faeces" (16.0 (4.10) x10(- 2) U/mg protein), mean 7 alpha-DH in the caecum (8.54 (1.08) x10(-4) U/mg protein) was higher (p<0.05) than that in the left colon (5.72 (0.85) x10(-4) U/mg protein). At both sites, 7 alpha-DH was significantly greater in the "high" than in the "low" serum DCA subgroups. CA concentrations in the right colon (0.94 (0.08) micromol/ml) were higher than those in the left (0.09 (0.03) micromol/ml; p<0.001) while in the caecum (but not in the faeces) there was a weak (r=0.58) but significant (p<0.005) linear relationship between 7 alpha-DH and CA concentration. At both sites, 7 alpha-DH was linearly related (p<0.005) to per cent DCA in serum. INTERPRETATION/SUMMARY: These results: (i) confirm that there are marked regional differences in bile acid metabolism between the right and left halves of the colon, (ii) suggest that caecal and faecal 7 alpha-DH influence per cent DCA in serum (and, by inference, in bile), and (iii) show that the substrate CA induces the enzyme 7 alpha-DH in the caecum.

Colonic transit influences deoxycholic acid kinetics

BACKGROUND & AIMS

Prolonged large bowel transit, and an increase in the proportion of deoxycholic acid (DCA), have been implicated in the pathogenesis of cholesterol gallstones-including those developing in acromegalics treated with octreotide. However, there are few data on the effects of intestinal transit on bile acid kinetics.

METHODS

We therefore measured the kinetics of DCA and cholic acid (CA) using stable isotopes, serum sampling, and mass spectrometry. The results were related to mouth-to-caecum (MCTT) and large bowel transit times (LBTTs) in 4 groups of 8 individuals: (1) non-acromegalic controls, (2) acromegalics untreated with octreotide, (3) acromegalics on long-term octreotide, and (4) patients with constipation. Paired, before and during octreotide, studies were performed in 5 acromegalics.

RESULTS

In the unpaired and paired studies, octreotide significantly prolonged MCTT and LBTT. In the paired studies, the octreotide-induced prolongation of LBTT caused an increase in the DCA input rate (6.4 +/- 2.8 to 12 +/- 2.6 micromol. kg. d, P < 0.05) and pool size (18 +/- 12 to 40 +/- 13 micromol/kg, P < 0.05), and a decrease in CA pool size (45 +/- 15 to 25 +/- 11 micromol/kg, P < 0.05). Furthermore, during octreotide treatment, the mean conversion of 13C-CA to 13C-DCA (micromoles) was greater (P < 0.05) on study days 3, 4, and 5. There were also positive linear relationships between LBTT and DCA input rate (r = 0.78), pool size (r = 0.82, P < 0.001), and a weak (r = -0.49) negative linear relationship between LBTT and CA pool size (P < 0.01).

CONCLUSIONS

These data support the hypothesis that, by increasing DCA formation and absorption, prolongation of large bowel transit is a pathogenic factor in the formation of octreotide-induced gallstones.