Epigastric Pressure Research Articles

FRI643 Tirzepatide Associated Partial Small Bowel Obstruction: A Case Report

Abstract Disclosure: A. Mathew: None. H. Hannoodee: None. Glucagon-like peptide-1 receptor agonists (GLP1 RA) are quickly becoming an adjunctive treatment modality for people with type-2 diabetes and is approved for chronic weight management. Tirzepatide has a dual GIP/GLP-1 RA action and has a synergistic effect when administered together. GLP-1 RA are associated with improved cardiovascular and all-cause mortality outcomes in patients with type-2 diabetes. Tirzepatide is associated with gastrointestinal (GI) side effects like nausea, diarrhea, abdominal pain, decreased appetite, and constipation. This case report discusses a case of small bowel obstruction (SBO) that was noted after patient was changed from dulaglutide to tirzepatide. Mr. X is a 61 y/o male with PMHx of type-2 DM, HTN, and HLD who presented to ER for severe epigastric pressure- like 7/10 abdominal pain. No association with food intake. He had 1 episode of semi-loose stools. Denied any abdomen cramping, sick contacts, nausea/vomiting, fever/chills, or constipation. His previous endoscopy was only relevant for benign colonic polyps, which were removed. He had been on GLP1 RA for more than a year, and previously on dulaglutide 3mg, which was switched to tirzepatide 2.5mg 5 weeks ago. He was able to tolerate the medication without significant side effects and was recently up-titrated to 5 mg. Labs showed WBC 7.2, Hb 13.6, Cr 1.45, BUN 12, lipase 25, and normal LFTs. Abdominal X-ray and CT abdomen were noted to be significant for a partial vs evolving SBO without any identifiable small bowel intrinsic pathology. Mr. X was managed conservatively with fluids, NPO diet, and pain medications. Serial abdominal images were obtained, and he was eventually advanced to soft diet. Tirzepatide was discontinued on discharge. As a response to enteral nutrition, distal small bowel and colon release GLP-1 hormone. Exogenous and endogenous GLP-1 are associated with reduced gastric motility. GLP 1 RA and dual GIP/GLP-1 RA are advised to be used with caution in patients with established gastroparesis, as they can worsen the symptoms. GLP-1 effect on small intestinal motility is not extensively studied, however, small bowel motility inhibition was noted in animal models. Some of these actions were dose-dependent. There are some case reports of SBO due to GLP-1 RA. An observational cohort study noted an increased incidence of SBO with GLP1 RA when compared to SGLT2i. They noted most incidents of SBO happened early within the initiation of therapy (within 3 months). At the time of writing this abstract, there are no published SBO case reports associated with tirzepatide. Further large-scale clinical trials need to be conducted to explore the association of SBO in patients with GIP/GLP-1 and GLP-1 RA. These studies will help guide if these drugs should be contraindicated or used with caution in people with a previous history of SBO or colonic obstruction. Presentation: Friday, June 16, 2023

Gastric administration of garlic powder containing the trpa1- agonist allicin induces specific epigastric symptoms and gastric relaxation in healthy subjects.

TRPA1 is an excitatory ion channel and is involved in sensory processes including thermal nociception and inflammatory pain. The allicin in garlic is a strong activator of the TRPA1 channel. To evaluate the effect of intragastric garlic powder containing allicin on perception, gastric tone, and mechanosensitivity. An infusion-barostat balloon assembly was used for infusion of test solutions, for distension, and to measure proximal gastric compliance and tone. After an initial open label dose finding with 1g, 2g, 3.75g, and 7.5g commercially available garlic powder, a bolus of 2g garlic powder (11mg allicin)/60mL H2 O was considered to induce moderate but constant sensation and was used hereafter in a placebo-controlled, single-dose, double-blind, randomized study in 7 volunteers to evaluate gastric sensation, tone, and mechanosensitivity. Bolus injection of garlic caused immediate epigastric symptoms, mean aggregate symptom scores (AUC in 15minutes) were 106±49 vs. 35±30 after placebo (P=0.01). Garlic induced significant epigastric pressure, stinging, and warmth (P<0.01 vs. placebo), while intensity of cramps, satiety, nausea, and pain was not significantly different to placebo (P>0.05). Garlic induced an immediate, short lived fundic relaxation (balloon volume 627±349mL vs. -145±120mL; P<0.02). No effect of allicin on proximal gastric mechanosensitivity and compliance was observed (NS). Garlic containing allicin induces immediate epigastric symptoms of pressure, stinging, and warmth and induces fundic relaxation but does not influence mechanosensitivity or compliance. TRPA1 is a receptor that is involved in gastric sensation and motility.

Prevalence of functional dyspepsia and its subgroups in patients with eating disorders

To study the prevalence of functional dyspepsia (FD) (Rome III criteria) across eating disorders (ED), obese patients, constitutional thinner and healthy volunteers. Twenty patients affected by anorexia nervosa, 6 affected by bulimia nervosa, 10 affected by ED not otherwise specified according to diagnostic and statistical manual of mental disorders, 4th edition, nine constitutional thinner subjects and, thirty-two obese patients were recruited from an outpatients clinic devoted to eating behavior disorders. Twenty-two healthy volunteers matched for age and gender were enrolled as healthy controls. All participants underwent a careful clinical examination. Demographic and anthropometric characteristics were obtained from a structured questionnaires. The presence of FD and, its subgroups, epigastric pain syndrome and postprandial distress syndrome (PDS) were diagnosed according to Rome III criteria. The intensity-frequency score of broader dyspeptic symptoms such as early satiety, epigastric fullness, epigastric pain, epigastric burning, epigastric pressure, belching, nausea and vomiting were studied by a standardized questionnaire (0-6). Analysis of variance and post-hoc Sheffè tests were used for comparisons. 90% of patients affected by anorexia nervosa, 83.3% of patients affected by bulimia nervosa, 90% of patients affected by ED not otherwise specified, 55.6% of constitutionally thin subjects and 18.2% healthy volunteers met the Postprandial Distress Syndrome Criteria (χ(2), P < 0.001). Only one bulimic patient met the epigastric pain syndrome diagnosis. Postprandial fullness intensity-frequency score was significantly higher in anorexia nervosa, bulimia nervosa and ED not otherwise specified groups compared to the score calculated in the constitutional thinner group (4.15 ± 2.08 vs 1.44 ± 2.35, P = 0.003; 5.00 ± 2.45 vs 1.44 ± 2.35, P = 0.003; 4.10 ± 2.23 vs 1.44 ± 2.35, P = 0.002, respectively), the obese group (4.15 ± 2.08 vs 0.00 ± 0.00, P < 0.001; 5.00 ± 2.45 vs 0.00 ± 0.00, P < 0.001; 4.10 ± 2.23 vs 0.00 ± 0.00, P < 0.001, respectively) and healthy volunteers (4.15 ± 2.08 vs 0.36 ± 0.79, P < 0.001; 5.00 ± 2.45 vs 0.36 ± 0.79, P < 0.001; 4.10 ± 2.23 vs 0.36 ± 0.79, P < 0.001, respectively). Early satiety intensity-frequency score was prominent in anorectic patients compared to bulimic patients (3.85 ± 2.23 vs 1.17 ± 1.83, P = 0.015), obese patients (3.85 ± 2.23 vs 0.00 ± 0.00, P < 0.001) and healthy volunteers (3.85 ± 2.23 vs 0.05 ± 0.21, P < 0.001). Nausea and epigastric pressure were increased in bulimic and ED not otherwise specified patients. Specifically, nausea intensity-frequency-score was significantly higher in bulimia nervosa and ED not otherwise specified patients compared to anorectic patients (3.17 ± 2.56 vs 0.89 ± 1.66, P = 0.04; 2.70 ± 2.91 vs 0.89 ± 1.66, P = 0.05, respectively), constitutional thinner subjects (3.17 ± 2.56 vs 0.00 ± 0.00, P = 0.004; 2.70 ± 2.91 vs 0.00 ± 0.00, P = 0.005, respectively), obese patients (3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001; 3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001 respectively) and, healthy volunteers (3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.002; 3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.001, respectively). Epigastric pressure intensity-frequency score was significantly higher in bulimic and ED not otherwise specified patients compared to constitutional thin subjects (4.67 ± 2.42 vs 1.22 ± 1.72, P = 0.03; 4.20 ± 2.21 vs 1.22 ± 1.72, P = 0.03, respectively), obese patients (4.67 ± 2.42 vs 0.75 ± 1.32, P = 0.001; 4.20 ± 2.21 vs 0.75 ± 1.32, P < 0.001, respectively) and, healthy volunteers (4.67 ± 2.42 vs 0.67 ± 1.46, P = 0.001; 4.20 ± 2.21 vs 0.67 ± 1.46, P = 0.001, respectively). Vomiting was referred in 100% of bulimia nervosa patients, in 20% of ED not otherwise specified patients, in 15% of anorexia nervosa patients, in 22% of constitutional thinner subjects, and, in 5.6% healthy volunteers (χ(2), P < 0.001). PDS is common in eating disorders. Is it mandatory in outpatient gastroenterological clinics to investigate eating disorders in patients with PDS?

Vagal response varies with valsalva maneuver technique: A repeated-measures clinical trial in healthy subjects

Study objective Variable success rates of the Valsalva maneuver in treatment of paroxysmal supraventricular tachycardia may be due to variations in performance technique. This study aimed to compare the magnitude of the vagal reflexes initiated by 5 variations of the Valsalva maneuver technique (supine, supine with epigastric pressure, supine with leg raise, semirecumbent position, and sitting position). Methods This was a single-blinded, repeated-measures, clinical trial of 65 subjects in sinus rhythm. Subjects performed each Valsalva maneuver technique 5 times in random order. The means of the longest ECG R-R intervals during the relaxation phase (postmaneuver R-R interval) and the postmaneuver pulse rates for each technique were compared. The mean differences between the pre- and postmaneuver R-R intervals for each technique were also compared. Results The supine with epigastric pressure and supine techniques resulted in longer mean postmaneuver R-R intervals (1.082 seconds [95% confidence interval (CI) 1.045 to 1.119 seconds] and 1.075 seconds [95% CI 1.035 to 1.114 seconds], respectively) than the leg raise, semirecumbent, and sitting position techniques (1.053 seconds [95% CI 1.019 to 1.086 seconds], 1.044 seconds [95% CI 1.006 to 1.081 seconds], and 1.024 seconds [95% CI 0.990 to 1.059 seconds], respectively), which equates to slower mean postmaneuver pulse rates for the supine with epigastric pressure and supine techniques (55.5 and 55.8 beats/min, respectively) than the leg raise, semirecumbent, and sitting position techniques (57.0, 57.5, and 58.6 beats/min, respectively). The supine with epigastric pressure and supine techniques also resulted in the largest premaneuver versus postmaneuver differences. Conclusion For healthy subjects in sinus rhythm, the supine with epigastric pressure and supine techniques generated stronger vagal responses, as measured by R-R intervals and pulse rates, than the other techniques examined. However, the vagal responses of these 2 techniques were similar, and the addition of epigastric pressure may confer little advantage.

Prospective Epidemiologic Study of Epigastric Discomfort (PRESTO). Ground work and preliminary results

Symptoms of dyspepsia (indigestion; upper abdominal discomfort) are one of the most frequent reasons for consulting a general practitioner or internist. Yet there are no up-to-date national data on the epidemiology and course of this symptom complex. In an open, prospective, multicentre, epidemiological study (PRESTO) 3016 patients with the suspected diagnosis of "functional dyspepsia" (1228 males, 1788 females, mean age 50 +/- 15 years) were followed for 2 years by 983 physicians in private practice (general practitioners or specialists in internal medicine). Patients with proven gastro-oesophageal reflux or peptic ulcer were excluded. Treatment was at the discretion of the physician. Patients were seen after one month (if under treatment) and then at 6, 12, 18 and 24 months. In addition to personal data, (1) symptoms, diagnosis and treatment of the dyspepsia, (2) socioeconomic aspects and (3) any limitations and the quality of life of each patient were recorded in a standard manner. At the first interim analysis more than half the patients judged there situation to be one of "chronic stress" or having to cope with a stressful event; nearly 50% thought this to be the cause of the symptoms. Concomitant illnesses were present in 63% of patients. Oesophagogastroduodenoscopy with subsequent medication was performed in 20.6%, a trial of medication (usually drugs stimulating gastric motility) in 65%. No medication was initially given to 14.4% of patients. The most common symptoms were feeling of fullness (92.9%, epigastric pressure sensation (91.5%) and flatulence (87.4%). These preliminary results indicate that a large epidemiological study can be performed by general practitioners and has advantages over the more usual method of enquiry by telephone. Dyspepsia exerts an unusually high degree of stress and results in considerable demands on medical facilities.

Case 44-1990

Presentation of CaseA 71-year-old woman was admitted to the hospital with biventricular congestive heart failure and a pericardial effusion.The patient was well and active until four months earlier, when she began to have epigastric "pressure" on exertion, sometimes accompanied by dyspnea and relieved by one minute of rest. About the same time she also noticed the onset of an intermittent petechial rash that tended to occur at points of contact or friction with her clothing.Two months before entry a prolonged episode of epigastric pressure and dyspnea occurred, and she was admitted to another hospital. An electrocardiogram showed . . .

Neurohypophyseal secretion in response to cholecystokinin but not meal-induced gastric distention in humans.

Exogenous administration of cholecystokinin octapeptide (CCK) is known to decrease food intake and slow gastric emptying in humans and animals. Recent studies have shown that CCK stimulates neurohypophyseal secretion of oxytocin (OT) in rats and arginine vasopressin (AVP) in monkeys, and that gastric distention also stimulates OT release in rats. We therefore studied AVP and OT secretion in 14 normal subjects in response to meal-induced gastric distention and administration of CCK, both separately and in combination, to assess whether these stimuli similarly activated central neurohypophyseal pathways in humans. Neither plasma AVP nor OT concentrations increased after gastric distention produced by ingestion of a large meal. However, a dose-related increase in plasma AVP, but not OT levels, occurred after CCK administration, the threshold CCK dose being 0.05 micrograms/kg body weight. The AVP secretion in response to CCK administration was significantly correlated with subjective aversive symptoms quantified by use of a numeric scale (r = 0.61, P less than 0.001). In 12 of the 14 subjects plasma AVP levels increased in association with symptoms of epigastric pressure and discomfort before the onset of overt nausea or emesis. The combination of CCK and meal-induced gastric distention did not stimulate increases in plasma AVP levels in excess of those produced by CCK administration alone. The results demonstrate that AVP secretion resulting from emetic center activation often is a graded response that can begin in association with milder degrees of visceral discomfort before symptoms of overt nausea or emesis. In addition, the stimulation of AVP secretion by CCK administration, but not by meal-induced gastric distention in association with physiological satiety, suggests that some component of the anorectic effects of exogenous CCK in man likely results from activation of brainstem emetic centers.

Benign Tumor of the Stomach

The final decision as to the malignancy or non-malignancy of a tumor must rest with the pathologist and is made from the histological examination of the suspected tumor. This necessitates the removal of the tumor. There are times when it is neither expedient nor advisable to remove the tumor. There are other times when from the history, examination, and X-ray studies doubt arises as to the class under which the tumor classifies, and “watchful waiting” seems to be the proper course. Benign tumors of the stomach are uncommon. In all the literature, not over one thousand cases have been recorded. These cases include all types of non-malignant tumors, such as papillomata, myomata, angiomata, polypi, adenomata, lipomata, cysts, fibromata, myxomata, and lymphadenomata. Carman found two cases in fifty thousand stomach X-ray examinations. The case to be described is the first seen by the writer in over six thousand X-ray examinations of the stomach. Most of the cases described have been confirmed post-operatively or at autopsy. A diagnosis of benign tumor of the stomach pre-operatively can be only presumptive at best, and yet there are certain roentgenologic characteristics of some types that have been described. With the larger visible tumors, there are certain constant features which tend to distinguish the benign from the malignant. Eliason and Wright in a study of fifty cases state: “The single tumors which are large enough to be describable stand out as globular, smooth, regular, clear, and persistent shadows, alike on the lesser and greater curvature, and by their very smooth uniform outline immediately strike one as not characteristic of the irregularity of malignancy or the scooped- or punched-out area of ulceration.” Inasmuch as the case to be described here seems to fit in with this description, and because of other features to be mentioned later, it is considered to be a case of benign tumor of the stomach. And, because of this, operation was held in abeyance. Subsequent events, since the first examination, have tended to substantiate this opinion. The patient, Mrs. K. J., housewife, age 42, was first seen on April 8, 1928. Her chief complaint was epigastric pressure. There was no regularity as to the occurrence of the attacks. One year previously she had had one series of attacks which had lasted about one month. The present series of attacks had begun four weeks before her visit to me. These attacks would come on as often as two or three times daily. Occasionally she would have a day free from attack. They came on about two hours after meals and lasted only a short time. Twice she had been awakened after midnight with bad attacks. Alkalis and walking seemed to offer the greatest relief. The attacks were associated with bloating and at times there was slight pain in the epigastrium, radiating straight through to the back. There was also a heaviness, with pressure, increased by lying on the right side.

THE PROBABLE ENDOCRINE ORIGIN OF PEPTIC ULCER

The consensus of opinion is that chronic ulcer in man develops from the acute ulcer, and that the acute ulcer must necessarily be preceded by an initial lesion. Once the initial lesion is formed, its further development through the various stages into the chronic ulcer is attributed to the corrosive action of the hydrochloric acid of the gastric juice. However, intrinsic causes, such as the mechanical irritation of food on the ulcerated area, and extrinsic causes, such as epigastric pressure from abnormal posture, are other agents helping to produce chronicity. The presence of hyperchlorhydria in conditions other than ulcer, and the absence of ulcer in true achylia gastrica, though occasionally lesions in the stomach may be present in the latter condition, are facts suggesting that hydrochloric acid is a secondary, though prominent, factor in effecting the beginning of an ulcer. It is not the main etiologic factor. Various theories have