Vomiting and dysphagia predict delayed gastric emptying in diabetic and nondiabetic subjects

Impact of Gastroparesis on Outcomes After Pancreas Transplantation

Background

Gastroparesis (GP) is a chronic disorder of the stomach characterized by delayed gastric emptying and frequently associated with longstanding diabetes. This is a single-center retrospective analysis designed to establish the prevalence and assess the impact on posttransplant outcomes of GP among pancreas transplant recipients.

Methods

Medical records for all recipients of pancreas transplants performed between January 2003 and December 2023 were reviewed. GP was defined by abnormal gastric-emptying scintigraphy or other motility study or a history of symptoms. Primary outcomes included graft loss and patient death. Clinical outcomes included length of stay after transplant and readmissions, including specifically for GP symptoms.

Results

Of 731 recipients, 156 (21%) were diagnosed with GP before transplant. Patients with GP were younger and more likely to be female individuals. Posttransplant, there was no difference in length of stay, graft survival, or patient survival. Patients with GP were more likely to be readmitted and to be specifically admitted for GP symptoms. Requirement for interventions was more common in patients with GP.

Conclusions

GP is identified with increased frequency among the specific patient population referred for pancreas transplant, and although it does not seem to affect allograft or patient survival, it does seem to have an impact on readmissions and the need for interventions.

Can an Abnormal Gastric Emptying Study Be Normal?

The American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine and Molecular Imaging collaboratively wrote consensus statements to standardize gastric emptying scintigraphy. Despite this, centers are using nonstandard protocols. This study examined how these protocols contrast with standards. Methods: Consecutive charts were analyzed for meal, radionuclide dose, half-emptying time (T½) and its normal range, and documented retention and emptying. Impressions were compared with how emptying mapped on a graph based on standard 4-h values. Results: Thirty-four studies were identified. Ten of 14 abnormal studies were normal when plotted on the standard 4-h graph. Eight of 10 abnormal studies had normal 2- or 4-h retention. Normal T½ ranges varied significantly. Most altered the meal, and over 25% received a radionucleotide dose outside the recommended range. Conclusion: The upper bound of normal T½ falls within standard 4-h bounds, with many individuals given an erroneous impression. Though further optimization may be needed, adhering to standards is critical.

Aerodigestoscopy (ADS): The Feasibility, Safety, and Comfort of a Comprehensive Procedure for the Evaluation of Physiological Disorders of the Aerodigestive Tract

Background: Limited access to the comprehensive assessment of disorders of the upper aerodigestive tract is a barrier to care in rural health facilities. Assessment of the full aerodigestive tract requires a variety of specialists. The inability to access the necessary specialists can result in misdiagnosis, underdiagnosis, and increased associated mortality. Currently, no single differential diagnostic exam comprehensively assesses all functions of the upper aerodigestive tract to bridge this gap. The purpose of this study is to investigate the feasibility and safety of a novel procedure called ADS that can bridge this gap. Methods: Results from 18,464 ADS procedures were retrospectively analyzed for feasibility, safety and comfort. Results: 96.8% of ADS procedures were successfully completed without complication, confirming the efficacy of the procedure. Conclusions: ADS is a single procedure for the assessment of physiological functions of the upper aerodigestive tract, including swallow, voice, respiration, and cough while also screening for impaired gastric retention and obstructive sleep apnea, which may pose additional urgent and emergent airway threats. ADS may improve health outcomes in underserved populations, e.g., those in a rural community, referred to by other health professionals due to complaints of aerodigestive symptoms and signs.

Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment

Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.

Meal Eating Characteristics of Patients with Gastroparesis

BACKGROUND

Patients with gastroparesis often consume only small meals due to early satiety.

AIMS

(1) Describe meal eating characteristics of patients with gastroparesis; (2) Relate meal eating characteristics to symptoms, gastric emptying (GE), and body weight.

METHODS

Patients with gastroparesis filled out questionnaires including Patient Assessment of Upper GI Symptoms (PAGI-SYM), and questionnaire about meal habits and body weight. Patients underwent gastric emptying scintigraphy.

RESULTS

Of 192 gastroparesis patients, 93% endorsed early satiety (ES) with severity of 3.7 ± 1.5 (scored from 0-5) and 93% endorsed postprandial fullness (PPF) with severity of 3.9 ± 1.3. Time spent consuming meals averaged 13.6 ± 17.7 min. Main reasons patients stopped eating were fullness (61%), nausea (48%), and abdominal pain (31%). Time spent eating correlated inversely with severity of nausea (r = -0.18, p < 0.05), stomach fullness (r = -0.21, p < 0.01), PPF (r = -0.23, p < 0.01), loss of appetite (r = -0.34, p < 0.01). Postprandial fullness lasted for 316 ± 344 min. Duration of PPF correlated with nausea (r = 0.30, p < 0.01), retching (r = 0.29, p < 0.01), vomiting (r = 0.28, p < 0.01), stomach fullness (r = 0.33, p < 0.01), loss of appetite (r = 0.35, p < 0.01), and constipation (r = 0.27, p < 0.01). Underweight patients had increased inability to finish a normal size meal (p < 0.01), loss of appetite (p < 0.01), and lower abdominal pain/discomfort (p < 0.05). Patients had lost 3.06 ± 10.60 kgs from their baseline weight. Weight loss correlated with nausea (r = 0.26, p < 0.01), ES (r = 0.30, p < 0.01), loss of appetite (r = 0.28, p < 0.01).

CONCLUSIONS

Early satiety and postprandial fullness were common with high severity. The main reasons for meal cessation were early satiety, nausea, and abdominal pain. Body weight and change in body weight were associated with symptoms of gastroparesis.

Comparison of High-Resolution Manometry in Patients Complaining of Dysphagia among Patients with or without Diabetes Mellitus

INTRODUCTION

Dysphagia is a common symptom that occurs in patients with diabetes mellitus (DM). There have been few prospective observational studies on esophageal motility disorders in DM using high-resolution manometry (HRM). This study aimed to clarify the characteristics of esophageal motility disorders using HRM in patients with dysphagia and compare them between DM and non-DM patients.

METHODS

Patients with dysphagia were prospectively recruited between October 2018 and July 2019. Patients (n = 89) underwent esophagogastroduodenoscopy and HRM and completed the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. Manometry parameters and motility disorder classifications were compared between DM and non-DM patients. We also investigated the differences in clinical backgrounds and questionnaire scores among DM patients with normal and abnormal manometry results.

RESULTS

A higher prevalence of esophageal motility disorder was observed in DM patients (60%, 21/35) compared to non-DM patients (29.6%, 16/54) (p = 0.001). The prevalence of minor disorders such as ineffective esophageal motor disorder and fragmented peristalsis was significantly higher (45 vs. 11%), and the distal contractile integral, integrated relaxation pressure, and contractile front velocity values were lower in the DM group. Among DM patients, those with abnormal esophageal motility had a significantly higher prevalence of neuropathy, retinopathy, and nephropathy, as well as higher reflux or constipation scores on the GSRS, than those with normal results.

CONCLUSIONS

Among patients with dysphagia, the frequency of minor esophageal motility disorders was higher in DM patients than in non-DM patients. Abnormal esophageal motility related to poor esophageal clearance was associated with higher prevalence of diabetic complications.

Role of Gastric Emptying in Symptoms of Gastroparesis

The symptoms of gastroparesis, such as nausea, vomiting, postprandial fullness, early satiety and abdominal pain, frequently impair the quality of life of the affected individuals. The diagnosis of gastroparesis is made after structural etiologies are ruled out and an assessment of gastric function shows delayed gastric emptying. The role of the delay in gastric emptying in the pathogenesis of symptoms of gastroparesis has been debated, with some studies suggesting an association between delayed gastric emptying and the upper gastrointestinal symptoms, while others do not. The recent literature supports the importance of using reliable methods to assess gastric emptying, as delay in gastric emptying measured on a reliable test (4-h scintigraphy or breath test) is associated with the severity of upper gastrointestinal symptoms. In addition to measuring total gastric emptying, evaluation of regional gastric retention in the proximal and distal stomach and whole gut transit to assess small intestinal and colonic transit may provide additional useful information in patients with more generalized symptoms of gastrointestinal dysmotility.

Association between delayed gastric emptying and upper gastrointestinal symptoms: a systematic review and meta-analysis

BACKGROUND

The relationship between delayed gastric emptying and upper GI symptoms (UGI Sx) is controversial.

OBJECTIVE

To assess association between gastric emptying and UGI Sx, independent of treatment.

DESIGN

We performed a systematic review and meta-analysis of the literature from 2007 to 2017, review of references and additional papers identified by content expert. We included studies evaluating the association between gastric emptying and nausea, vomiting, early satiety/postprandial fullness, abdominal pain and bloating. Covariate analyses included optimal gastric emptying test method, gastric emptying type (breath test or scintigraphy) and patient category. Meta-regression compared the differences based on type of gastric emptying tests.

RESULTS

Systematic review included 92 gastric emptying studies (26 breath test, 62 scintigraphy, 1 ultrasound and 3 wireless motility capsule); 25 of these studies provided quantitative data for meta-analysis (15 scintigraphy studies enrolling 4056 participants and 10 breath test studies enrolling 2231 participants). Meta-regression demonstrated a significant difference between optimal and suboptimal gastric emptying test methods when comparing delayed gastric emptying with nausea and vomiting. On evaluating studies using optimal gastric emptying test methodology, there were significant associations between gastric emptying and nausea (OR 1.6, 95% CI 1.4 to 1.8), vomiting (OR 2.0, 95% CI 1.6 to 2.7), abdominal pain (OR 1.5, 95% CI 1.0 to 2.2) and early satiety/fullness (OR 1.8, 95% CI 1.2 to 2.6) for patients with UGI Sx; gastric emptying and early satiety/fullness in patients with diabetes; gastric emptying and nausea in patients with gastroparesis.

CONCLUSIONS

The systematic review and meta-analysis supports an association between optimally measured delayed gastric emptying and UGI Sx.

Pathophysiology of idiopathic gastroparesis and implications for therapy

OBJECTIVES

Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis.

MATERIALS AND METHODS

Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases.

RESULTS

Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment.

CONCLUSIONS

Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.

Glucose-independent segmental phase angles from multi-frequency bioimpedance analysis to discriminate diabetes mellitus

We investigated segmental phase angles (PAs) in the four limbs using a multi-frequency bioimpedance analysis (MF-BIA) technique for noninvasively diagnosing diabetes mellitus. We conducted a meal tolerance test (MTT) for 45 diabetic and 45 control subjects stratified by age, sex and body mass index (BMI). HbA1c and the waist-to-hip-circumference ratio (WHR) were measured before meal intake, and we measured the glucose levels and MF-BIA PAs 5 times for 2 hours after meal intake. We employed a t-test to examine the statistical significance and the area under the curve (AUC) of the receiver operating characteristics (ROC) to test the classification accuracy using segmental PAs at 5, 50, and 250 kHz. Segmental PAs were independent of the HbA1c or glucose levels, or their changes caused by the MTT. However, the segmental PAs were good indicators for noninvasively screening diabetes In particular, leg PAs in females and arm PAs in males showed best classification accuracy (AUC = 0.827 for males, AUC = 0.845 for females). Lastly, we introduced the PA at maximum reactance (PAmax), which is independent of measurement frequencies and can be obtained from any MF-BIA device using a Cole-Cole model, thus showing potential as a useful biomarker for diabetes.

Gastric Motor Dysfunction in Patients With Functional Gastroduodenal Symptoms

OBJECTIVES

The pathophysiology of dyspeptic symptoms is complex. The aim of this study was to evaluate the association of gastric emptying (GE), gastric accommodation (GA), and respiratory sinus arrhythmia (RSA, to assess vagal dysfunction) in a large cohort with functional gastroduodenal symptoms.

METHODS

We reviewed demographic, clinical features, and results of gastric motor and vagal function studies of 1,287 patients (74.0% females, mean age 43.1±15.4 years) who had undergone both single photon emission computed tomography GA and scintigraphic GE. Accommodation was based on postprandial to fasting gastric volume ratio (VR). Electrocardiograms were available and analyzed for RSA in 300 patients.

RESULTS

There were 29.8% patients with normal GE and GA, 21.9% with abnormal GA only, 27.1% with abnormal GE only, and 21.1% with abnormal GA and GE. There were numerical differences in GA among patients with normal, accelerated, and delayed GE (P=0.062, by χ²). Increased GA (VR >3.85) was more prevalent in patients with delayed GE compared to accelerated GE (14.0% vs. 6.8%, P=0.004). Decreased VRs (median 2.9) were observed with accelerated GE compared to normal GE (median 3.1, P<0.05). Nausea and vomiting were more prevalent (in contrast to the less prevalent bloating) in patients with delayed compared to accelerated or normal GE (all P<0.05). In patients with diminished RSA, there was higher prevalence of reduced GA (41.5%) compared to those with preserved RSA (29.2%, P=0.031). Multivariable analysis showed associations of the main abdominal symptoms with gender, body mass index, gastric emptying, diabetes, and prior abdominal surgery.

CONCLUSIONS

Patients with symptoms of functional gastroduodenal disorders may have one or more gastric motor dysfunctions and reduced RSA; among the patients with abnormal gastric motor functions, vomiting suggests delayed GE, whereas reduced RSA is associated with reduced GA.