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Nightingale JMD, Paine P, McLaughlin J, Emmanuel A, Martin JE, Lal S. The management of adult patients with severe chronic small intestinal dysmotility. Gut 2020; 69:2074-2092. [PMID: 32826308 PMCID: PMC7677490 DOI: 10.1136/gutjnl-2020-321631] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and parenteral nutrition.
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Affiliation(s)
| | - Peter Paine
- Gastroenterology, Salford Royal Foundation Trust, Salford, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Salford, UK
| | | | - Joanne E Martin
- Pathology Group, Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Simon Lal
- Gastroenterology and Intestinal Failure Unit, Salford Royal Foundation Trust, Manchester, UK
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Nakagawa K, Hara K, Fikree A, Siddiqi S, Woodland P, Masamune A, Aziz Q, Sifrim D, Yazaki E. Patients with dyspepsia have impaired mucosal integrity both in the duodenum and jejunum: in vivo assessment of small bowel mucosal integrity using baseline impedance. J Gastroenterol 2020; 55:273-280. [PMID: 31468184 PMCID: PMC7026227 DOI: 10.1007/s00535-019-01614-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent studies reported that impaired proximal duodenal mucosa, assessed by duodenal biopsy, could play an important role in the development of dyspeptic symptoms. The aims of this study were (a) to develop a method to measure "in vivo" duodenal and jejunal baseline impedance (BI) and (b) to assess small bowel mucosal integrity in patients with functional dyspepsia (FD) and healthy controls (HC). METHODS We recruited 16 patients with FD and 15 HC. All subjects underwent ambulatory duodeno-jejunal manometry combined with impedance (HRM/Z), BI were determined by measuring impedance immediately after the passage of nocturnal migrating motor complex (MMC) phase IIIs. RESULTS The number of MMC phase IIIs in FD was significantly lower than that in HC (2.6 ± 1.4 vs 4.8 ± 1.7, p < 0.001). The BI in patients was significantly lower than that in HC in D1(164.2 ± 59.8 Ω in FD and 243.1 ± 40.5 Ω in HC, p = 0.0061), D2 (191.2 ± 34.1 and 256.5 ± 91.4 Ω, p = 0.01), D3 (214.0 ± 76.9 and 278.1 ± 45.3 Ω, p = 0.009), D4 (270.8 ± 54.2 and 351.8 ± 50.2 Ω, p < 0.001), and J1 (312.2 ± 55.4 and 379.3 ± 38.3 Ω, p = 0.001). CONCLUSIONS This is the first study reporting the duodenal and jejunal BI in vivo. The results have shown significantly lowered BI in the proximal small intestine in patients with FD compared to HC. Furthermore it suggests that measurements of small bowel BI could be used as a biomarker for diagnosis and follow up of patients with FD.
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Affiliation(s)
- Kenichiro Nakagawa
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, 980-8574 Japan
| | - Ken Hara
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
- Division of Gastroenterology, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, 663-8501 Hyogo Japan
| | - Asma Fikree
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Shahab Siddiqi
- Division of General Surgery, Broomfield Hospital, Court Rd, Broomfield, Chelmsford, CM1 7ET UK
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, 980-8574 Japan
| | - Qasim Aziz
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
| | - Etsuro Yazaki
- Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, Whitechapel, London, E1 AJ UK
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Halim MA, Gillberg L, Boghus S, Sundbom M, Karlbom U, Webb DL, Hellström PM. Nitric oxide regulation of migrating motor complex: randomized trial of N(G)-monomethyl-L-arginine effects in relation to muscarinic and serotonergic receptor blockade. Acta Physiol (Oxf) 2015; 215:105-18. [PMID: 26176347 DOI: 10.1111/apha.12554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 05/28/2015] [Accepted: 07/08/2015] [Indexed: 12/13/2022]
Abstract
AIM The migrating motor complex (MMC) propels contents through the gastrointestinal tract during fasting. Nitric oxide (NO) is an inhibitory neurotransmitter in the gastrointestinal tract. Little is known about how NO regulates the MMC. In this study, the aim was to examine nitrergic inhibition of the MMC in man using N(G)-monomethyl-L-arginine (L-NMMA) in combination with muscarinic receptor antagonist atropine and 5-HT3 receptor antagonist ondansetron. METHODS Twenty-six healthy volunteers underwent antroduodenojejunal manometry for 8 h with saline or NO synthase (NOS) inhibitor L-NMMA randomly injected I.V. at 4 h with or without atropine or ondansetron. Plasma ghrelin, motilin and somatostatin were measured by ELISA. Intestinal muscle strip contractions were investigated for NO-dependent mechanisms using L-NMMA and tetrodotoxin. NOS expression was localized by immunohistochemistry. RESULTS L-NMMA elicited premature duodenojejunal phase III in all subjects but one, irrespective of atropine or ondansetron. L-NMMA shortened MMC cycle length, suppressed phase I and shifted motility towards phase II. Pre-treatment with atropine extended phase II, while ondansetron had no effect. L-NMMA did not change circulating ghrelin, motilin or somatostatin. Intestinal contractions were stimulated by L-NMMA, insensitive to tetrodotoxin. NOS immunoreactivity was detected in the myenteric plexus but not in smooth muscle cells. CONCLUSION Nitric oxide suppresses phase III of MMC independent of muscarinic and 5-HT3 receptors as shown by nitrergic blockade, and acts through a neurocrine disinhibition step resulting in stimulated phase III of MMC independent of cholinergic or 5-HT3 -ergic mechanisms. Furthermore, phase II of MMC is governed by inhibitory nitrergic and excitatory cholinergic, but not 5-HT3 -ergic mechanisms.
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Affiliation(s)
- M A Halim
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - L Gillberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - S Boghus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - M Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - U Karlbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - D-L Webb
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - P M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Lammers WJEP, Michiels B, Voeten J, Ver Donck L, Schuurkes JAJ. Mapping slow waves and spikes in chronically instrumented conscious dogs: automated on-line electrogram analysis. Med Biol Eng Comput 2008; 46:121-9. [PMID: 18200451 DOI: 10.1007/s11517-007-0294-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 09/06/2007] [Indexed: 10/22/2022]
Abstract
Myoelectric recordings from the gastrointestinal (GI) tract in conscious animals have been limited in duration and site. Recently, we have implanted 24 electrodes and obtained electrograms from these sites simultaneously (200 Hz sampling rate; 1.1 MB/min data stream). An automated electrogram analysis was developed to process this large amount of data. Myoelectrical recordings from the GI tract often consist of slow wave deflections followed by one or more action potentials (=spike deflections) in the same traces. To analyze these signals, a first module separates the signal into one containing only slow waves and a second one containing only spikes. The timings of these waveforms were then detected, in real time, for all 24 electrograms, in a separate slow wave detection module and a separate spike-detection module. Basic statistics such as timing and amplitudes and the number of spikes per slow wave were performed and displayed on-line. In summary, with this online analysis, it is possible to study for long periods of time and under various experimental conditions major components of gastrointestinal motility.
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Affiliation(s)
- Wim J E P Lammers
- Department of Physiology, Faculty of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates.
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Aytuğ N, Giral A, Imeryüz N, Enç FY, Bekiroğlu N, Aktaş G, Ulusoy NB. Gender influence on jejunal migrating motor complex. Am J Physiol Gastrointest Liver Physiol 2001; 280:G255-63. [PMID: 11208548 DOI: 10.1152/ajpgi.2001.280.2.g255] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The role of gender and the menstrual cycle in small bowel motility has not been clearly elucidated. Jejunal motility was recorded with a nasojejunal catheter incorporating five solid-state pressure transducers in ambulatory menstruating women and men of comparable age over 24 h. All women were studied twice, in the early follicular (early-F) and midluteal (mid-L) phases of the menstrual cycle, verified by determining serum levels of gonadal steroids and gonadotropins. The propagation velocity of phase III was slow and the contraction amplitude was high in both menstrual cycle phases compared with men, and these parameters were correlated with serum estrogen levels in the mid-L phase. In the early-F phase, migrating motor complex (MMC) cycle duration during sleep was long compared with other groups and positively correlated with estrogen concentrations, whereas in the mid-L phase MMC cycle duration during sleep was negatively correlated with serum progesterone levels. In all groups, the frequency of phase III contractions was low and the intercontractile interval measured from pressure peak to peak was long during sleep compared with the awake state. Postprandial motility did not display gender difference in any parameter examined. The results demonstrate that the majority of patterns of motility are similar in menstruating women and men, whereas certain aspects of the MMC, most conspicuously propagation velocity and phase III contraction amplitude, differ. We have also documented circadian variation of phase III contraction frequency in both women and men.
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Affiliation(s)
- N Aytuğ
- Division of Gastroenterology, Department of Internal Medicine, University of Marmara School of Medicine, 81326 Haydarpaşa, Istanbul, Turkey
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