Gastric Emptying Studies Research Articles

Per-oral endoscopic pyloromyotomy (g-poem) for the treatment of gastroparesis – a pilot single-centre study with mid-term follow-up

Endoscopic pyloromyotomy (G-POEM) is an emerging therapeutic method for the treatment of gastroparesis (GP). So far, only limited case-series suggesting its effectivity have been published. The aim of our study was to assess the effectivity of G-POEM in patients with refractory GP. Consecutive patients with severe and refractory GP were offered the procedure. An abnormal gastric emptying study (GES) was necessary for inclusion. The main outcome was treatment success defined as adecrease of the total GSCI symptom score by at least 40% from baseline at 3, 6, 12 and 24 months. G-POEM was performed in 9 patients (5 women, mean age 56.3): 5 post-surgical, 2 diabetic, 1 idiopathic and 1 combined post-surgical and diabetic. The median follow-up was 23M (range 12-31). All procedures were successfully completed. One patient experienced delayed bleeding from gastric ulceration, which was successfully treated endoscopically; all remaining patients recovered uneventfully. Treatment success was achieved in 8/9 patients (88.9%) at 3, 6 and 12M and in 3/4 (75%) at 24M. The mean GSCI decreased from 3.16 to 0.86 (p=0.008), 0.74 (p=0.008), 1.07 (p=0.008) and 1.31 (p=0.11) at 3, 6, 12 and 24M after the procedure. The Quality of Life Index improved from the baseline value of 77 (range 48102) to 113 (86-138, p=0.03) and 96 (50-124, p=0.4) at 12 and 24M. In patients with treatment success, no recurrences have occurred so far. GES improved/normalized in all the patients. G-POEM was effective in 88.9% of patients with refractory GP and the effect seems to be long-lasting.

Delayed Gastric Emptying Is Not Associated with a Microbiological Diagnosis of Small Intestinal Bacterial Overgrowth.

Clinical symptoms of patients with small intestinal bacterial overgrowth (SIBO) may overlap with symptoms of gastroparesis. Prior studies suggest delayed small intestinal transit is associated with SIBO, but have not shown an association between delayed gastric emptying and SIBO. However, these studies have generally relied on the indirect method of breath testing to diagnose SIBO. The aim of this study was to examine the association between amicrobiological diagnosis of SIBO and delayed gastric emptying by scintigraphy. In a single-center retrospective study of previous research participants who presented for small bowel enteroscopy for diagnostic evaluation of SIBO, we identified 73 participants who underwent gastric emptying study by scintigraphy. A microbiological diagnosis of SIBO was made in patients based on culture results of jejunal aspirates. Clinical symptoms were assessed using the total gastroparesis cardinal symptom index (GCSI) score. We compared delayed gastric emptying, 2- and 4-h gastric retention, and gastroparesis symptoms between patients with and without a microbiological diagnosis of SIBO. Among 29 participants with SIBO and 44 without SIBO, 33 (45%) had evidence of delayed gastric emptying. There was no significant association between a microbiological diagnosis of SIBO and delayed gastric emptying by scintigraphy. Percent retained at 2 and 4h, and total GCSI scores did not differ significantly between those with and without SIBO. Although delayed gastric emptying is common in patients with suspected SIBO, gastric emptying is not associated with a microbiological diagnosis of SIBO.

Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video)

Endoluminal functional luminal imaging probe (EndoFLIP) is an imaging tool that measures the physiologic characteristics of GI sphincters. In this study, we used EndoFLIP to evaluate the association between the pyloric physiologic measurements and the clinical outcomes of gastric peroral endoscopic myotomy (G-POEM) in patients with refractory gastroparesis. Thirty-seven patients from 5 centers who underwent G-POEM for management of refractory gastroparesis and had EndoFLIP measurements were evaluated. Cross-sectional area (CSA), balloon pressure, and the distensibility index (DI) of the pylorus were evaluated by EndoFLIP at 40 mL and 50 mL balloon fills before and after G-POEM. One-year clinical success and change in gastric emptying study 3 months after the G-POEM procedure were compared with the EndoFLIP measurements. Clinical success was achieved in 26 (70%) patients. Post-G-POEM CSA and DI were significantly higher in the clinical success group with both 40-mL volume distension (CSA: 89.9 ± 64.8 vs 172.5 ± 71.9mm2, P=.003; DI: 5.8 ± 4.4 vs 8.8 ± 6.1mm2/mm Hg, P=.043) and 50-mL volume distention (CSA: 140.1 ± 89.9 vs 237.5 ± 80.3mm2, P=.003; DI: 5.6 ± 3.3 vs 9.9 ± 6.6mm2/mm Hg, P=.049). CSA using 40-mL volume distention with an area under the curve of 0.83 yielded a specificity of 91% and a sensitivity of 71% at a cutoff point of 154mm2. Post-G-POEM CSA of the pylorus is associated with clinical success and improvement in a gastric emptying scan after G-POEM. EndoFLIP measurements of the pylorus have the potential to be used as a tool to predict the clinical outcome of G-POEM.

Gastric emptying of milk in infants and children up to 5years of age: normative data and influencing factors.

Gastric emptying scintigraphy is widely used in infants and children, but there is a lack of age-specific normative data. The objectives of this retrospective study were: 1) to establish a range of gastric emptying of milk or formula as a surrogate for normal gastric emptying in infants and young children ≤5years of age, and 2) to investigate the effects of patient age, feeding volume, feeding route and gastroesophageal reflux on gastric emptying. The reports of 5,136 gastric emptying studies of children ≤5years of age performed at Children's National Medical Center from January 1990 to August 2012 were reviewed. Demographic data, 1-h and 3-h gastric emptying values and gastroesophageal reflux status of all patients were stored in a database. Using stringent inclusion and exclusion criteria, the studies of patients as similar to healthy children as possible were selected for this study. The study group included 2,273 children (57% male) ages 0-59months (median: 4.6months). The median 1-h gastric emptying was 43% (interquartile range [IQR] 34-54%). The median 3-h gastric emptying was 91% (IQR 79-98%). Sixty-one percent of patients with 1-h gastric emptying value of <50% had 3-h gastric emptying ≥80%. Gastric emptying was significantly faster in children ≤6months as compared with all older age groups. In each age group, the median gastric emptying decreased with increasing feeding volume. Gastric emptying was significantly faster in patients fed via combined nasogastric tube and oral routes as compared with those fed exclusively orally. There was no significant difference in gastric emptying of children with and without gastroesophageal reflux. Although there are statistically significant differences in gastric emptying based on age, volume and route of feeding, the data suggest that overall normal liquid gastric emptying in infants and children ≤5years of age is ≥80% at 3h. One-hour emptying measurements are not reliable for detecting delayed gastric emptying.

Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group.

Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

903 Clinical Efficacy of Gastric Per-Oral Endoscopic Myotomy in the Treatment of Refractory Gastroparesis and Predictors of Successful Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION: Options to treat medically refractory gastroparesis are limited. Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery that has shown promising results. Data is limited as to its efficacy, safety, predictive factors and its comparability to surgical pyloroplasty. The aim of our study was to synthesize and analyze the clinical outcomes of GPOEM by meta-analysis methods. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and surgical pyloroplasty in gastroparesis. Our primary outcome was to analyze the pooled rates of gastroparesis cardinal symptom index (GCSI) score and 4-hr gastric emptying study (GES) results, with G-POEM. Similar outcomes with surgical pyloroplasty was used as a comparator group. RESULTS: 332 and 375 patients underwent G-POEM (11studies) and pyloroplasty (7studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance,P = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with GPOEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, P = 0.91. The pooled rate of mean pre-G-POEM GCSI score was 3.4 (95% CI 3.1-3.7, I2 = 89) and post-G-POEM GCSI score was 1.8 (95% CI 1.4-2.1, I2 = 89), with statistical significance (P = 0.001). The pooled pre-G-POEM 4-hr GES was 49.9% (95% CI 41.6-58.3, I2 = 94) and post-G-POEM 4-hr GES was 20.6% (95% CI 12.3-28.8, I2 = 77), with statistical significance (P = 0.001). The pre and post pyloroplasty 4-hr GES results were 36% (95% CI 32.7-39.3, I2 = 88) and 3.9% (95% CI 2.3-5.5, I2 = 43), respectively (P = 0.001). The pre and post pyloroplasty GCSI score was not analyzed due to paucity in data. The overall adverse events were comparable (11%, 5.9-19.8, I2 = 66 vs 11.4%, 5-24, I2 = 69, P = 0.95). Based on meta-regression analysis, idiopathic-gastroparesis, prior treatment with botulinum toxin and gastric-stimulator seemed to predict clinical success with G-POEM. CONCLUSION: G-POEM demonstrates clinical success in treating refractory gastroparesis with comparable outcomes to pyloroplasty. Idiopathic gastroparesis, prior treatment with botulinum injection and gastric stimulator appear to have positive predictive effects on the 4-hr GES results after G-POEM.

453 Characterizing Esophageal Dysmotility in Patients With Post-Fundoplication Dysphagia

INTRODUCTION: Studies show that up to 90% of patients who undergo a fundoplication experience dysphagia post-operatively, and at least 10% of these patients' dysphagia will persist past 1 year. Little is known about possible causative etiologies. This project aims to manometrically characterize post-fundoplication dysphagia present in patients at least 1 year after surgery versus dysphagia controls with no prior history of gastric surgeries. METHODS: This is a single-center, retrospective chart review of patients who received a Nissen fundoplication for refractory GERD and were seen between January 2011 and February 2019 for post-fundoplication dysphagia lasting longer than 1 year before undergoing high resolution manometry (HRM). The 25 research subjects were matched to corresponding age, gender, and race-matched controls who were seen at the center for dysphagia during the same time period. The data collected includes demographics, symptoms, and findings from HRM, endoscopy, gastric emptying studies, pH impedance studies, and barium esophagrams. RESULTS: The mean lower esophageal sphincter respiratory basal pressure (LES RBP) was significantly lower in patients with fundoplication as compared to controls (P = 0.028). Patients with fundoplication had a significantly decreased distal contractile integral (DCI) as compared to controls (P = 0.0089). The ranges of DCI values between the two groups were notably different (subjects: 643-1500 mm Hg-cm-s; controls: 1654-3590 mm Hg-cm-s). Patients with post-fundoplication dysphagia were more likely to have a hypotensive LES (P = 0.096) and less likely to have a hypertensive LES (P = 0.023) compared to the dysphagia controls with no prior history of gastric surgery. Furthermore, they were more likely to have an esophageal dysmotility disorder—ineffective esophageal motility (43%), failed peristalsis (21%), fragmented peristalsis (7%), or diffuse esophageal spasm (29%) (P = 0.038). There were no significant differences between subjects and controls found in patient-reported symptoms, gastric emptying studies, pH impedance studies, barium esophagrams, and endoscopy reports. CONCLUSION: Many believe that esophageal hypomotility will improve in patients undergoing fundoplication for GERD. Our study demonstrates that post-fundoplication dysphagia is associated with higher rates of esophageal motor abnormalities, specifically esophageal hypomotility, when compared to dysphagia controls with no prior gastric surgical history.

420 Assessing the Prevalence of Gastroesophageal Reflux in Gastroparesis: Putting the G Back in GERD

INTRODUCTION: Patients with gastroparesis experience a wide range of symptoms from early satiety to frequent emesis and severe abdominal pain. However, few studies have evaluated concomitant underlying esophageal pathology or frequency of gastroesophageal reflux episodes in patients diagnosed with gastroparesis. Prolonged gastric emptying may lead to increased intra-gastric pressure and volume of gastric contents that may result in increased frequency of distal esophageal reflux events. The aim of this study was to assess for significant differences in total duration of distal esophagus acid exposure and number of gastroesophageal reflux events as detected by impedance pH testing between gastroparesis and control cohorts. METHODS: A retrospective analysis of 84 patient charts who underwent both 4-hour gastric emptying studies and 24-hour ambulatory pH testing was performed. Patients with gastroparesis, as documented by abnormal 4-hour gastric emptying studies, were compared with age and gender matched controls. Patients taking PPI during testing were excluded from the study. Percent of total distal esophageal time pH &lt; 4 (nl &lt; 4%) and impedance values (nl&lt; 53) were compared between the gastroparesis and control groups. Continuous variables were analyzed using independent 2-tailed t-test, while categorical values were evaluated using a chi squared analysis. RESULTS: Forty-two gastroparesis patients (9 men and 33 women, median age 46 years old, range 19-81 years old) underwent 24-hour ambulatory pH monitoring while off of PPI. When comparing total mean impedance events during pH testing, the gastroparesis cohort experienced significantly more episodes of distal esophageal reflux events, 61.27 ± 11.34 vs 45.81 ± 7.72 (P = 0.028), respectively. Mean percent total distal time for esophageal pH &lt; 4.0 was higher for the gastroparesis group when compared to controls, 4.79 ± 1.48% vs 3.31 ± 1.15% (P = 0.125), respectively. CONCLUSION: This pilot study demonstrates that patients meeting criteria for gastroparesis by gastric emptying study have significantly higher number of reflux episodes than those with normal gastric emptying. Trends toward a higher percentage of total distal esophageal acidity exposure time and a higher proportion of the gastroparesis group meeting diagnostic criteria for GERD were also seen. In the future, expanding sample sizes to better investigate these preliminary trends will be beneficial to better understand the association of GERD and gastroparesis.

30-Year-Old Woman With Intractable Vomiting

30-Year-Old Woman With Intractable Vomiting

1853 Impaired Gastric Accommodation: A Key Player in Functional Dyspepsia

INTRODUCTION: Poor gastric accommodation (GA) causes inadequate relaxation of the stomach during a meal. This leads to early satiety, fullness sensation, nausea, and vomiting. Poor GA is frequently seen in functional GI disorders and often coincided with anxiety and stress. It should be considered in the absence of metabolic disorders, eating disorders, and self-induced vomiting. Poor GA is quantified by the average increase of gastric volume after a meal over 1 hour. Poor GA is thought to be caused by altered neuro-modulatory pathways that affect accommodation time after a meal. CASE DESCRIPTION/METHODS: A 53-year-old woman with history of Type II Diabetes with Hba1c: 9.4%, complicated by diabetic neuropathy was admitted for treatment of UTI and Herpes Zoster. She also complained of new onset nausea, vomiting, and early satiety for 1 week. She could tolerate only thin liquids but no solids, due to persistent emesis within 10-20 min of food ingestion. An EGD was done and ruled out gastric outlet obstruction, but revealed candida esophagitis, which was treated with Fluconazole. The patient was then started empirically on Metoclopramide for presumptive Gastroparesis in the setting of poorly controlled Diabetes. The dose was gradually titrated up without favorable response. Her therapy was then escalated to Erythromycin along with Zofran and Benadryl, with no success. The patient was unable to complete a Gastric Emptying (GE) Study twice due to emesis following radiotracer ingestion. However, images from incomplete GE studies showed rapid movement of radiotracer from the fundus to the antrum. The patient was then switched to Buspirone 5 mg 30 minutes before lunch and dinner with remarkable improvement of her symptoms in 2 days. DISCUSSION: Early redistribution of radiotracer seen on scintigraphy is suggestive of impaired accommodation and is usually associated with early satiety, dyspepsia, nausea and vomiting. Rapid clinical improvement after 5-HT1a receptor agonist therapy not only implies anxiety and stress as contributing factors in this disorder, but also the role of presynaptic inhibitory 5-HT1a receptor activation in the gastric accommodation reflex. This allows for better stomach relaxation both in fasting and postprandial states. This therapy should be considered in patients with gastroparesis-like symptoms, but rapid gastric emptying seen on scintigraphy.

1206 Gastric Emptying Scans: Adherence to National Guidelines

INTRODUCTION: Gastric-emptying scintigraphy (GES), routinely used to measure gastric emptying, is an essential tool to diagnose gastroparesis. An accurate diagnosis of gastroparesis relies upon the GES being performed according to a validated protocol. Jointly published protocol guidelines have been available for over a decade; however, the extent to which these guidelines are adhered to is unknown. This study aimed to assess national compliance with established GES protocol guidelines. METHODS: We developed a questionnaire addressing key protocol measures outlined in the published Procedure Guideline for Adult Solid-Meal Gastric Emptying Study 3.0. Survey questions addressed patient information collection (15), patient preparation and procedure protocol (16), meal content and preparation (7), imaging (3), interpretation (4), and reporting (7). Demographic data was also collected. The anonymous questionnaire was distributed electronically to members of the Society of Nuclear Medicine and Medical Imaging (SNMMI) and non-member recipients of the SNMMI daily email newsletter. One response per medical institution was permitted. Data were entered manually and statistically assessed using JMP®, Version 14.0. SAS Institute Inc., Cary, NC. RESULTS: 121 medical institutions (MI) responded; 49 (40.4%) were academic/teaching medical centers. The mean number of annual GES procedures was 199.9 (range, 5 to 2000 GES/year). On average, MI performed 64% (33.5/52) of protocol measures according to guidelines while academic medical centers performed 61% (31.5/52) of protocol measures according to guidelines. Only 59% of MI use the validated meal. 42% of MI reported stopping imaging prior to the validated 4-hour interval. Only 16% of MI test blood glucose levels prior to GES while 71% cancel or reschedule GES if blood glucose levels are above the validated cut-off. 68% of MI ask patients if they take narcotic pain medications; only 49% require that patients stop taking narcotic pain medications at least two days prior to the GES. Only 4.5% of MI perform GES while adhering to 3 critical measures: validated study duration; controlling blood glucose levels; and properly restricting medication use. CONCLUSION: Low compliance with GES protocol guidelines, even among academic medical centers, raises the likely possibility of misdiagnosis and thus improper management of upper gastrointestinal symptoms. These results highlight a need for increased awareness of protocol guidelines.

Relationship between symptoms during a gastric emptying study and intestinal chemosensitivity with daily symptoms.

Non-ulcer dyspepsia (NUD) is a heterogeneous disorder, which is characterized by upper gastrointestinal symptoms and sensorimotor disturbances, including abnormal gastric emptying (GE) and increased intestinal chemosensitivity, and associated with greater plasma glucagon-like peptide-1 (GLP-1) levels during duodenal lipid infusion. However, the relationship(s) between these disturbances and daily symptoms in NUD is variable. We hypothesize that abnormal GE and symptoms during a GE study and during duodenal lipid infusion are associated with the severity of daily symptoms and that GLP-1 mediates symptoms during duodenal lipid infusion in NUD. Gastric emptying of solids, symptoms during the GE study and duodenal lipid infusion, and daily gastrointestinal symptoms (2week diary) were measured in 24 healthy controls and 40 NUD patients. During duodenal lipid infusion, participants received the GLP-1 antagonist exendin 9-39 or placebo. In controls and patients, GE of solids was normal in 75% and 75%, delayed in 8% and 12.5%, or rapid in 17% and 12.5%, respectively. No controls but 26 patients (65%) had severe symptoms during the GE study. During lipid infusion, gastrointestinal symptoms were greater (P=.001) in patients and not affected by exendin. Symptoms during GE study and lipid infusion accounted for respectively 62% and 37% of variance in daily symptom severity. In NUD, symptoms during a GE study and to a lesser extent during lipid infusion explain the variance in daily symptoms. Intestinal chemosensitivity is not reduced by GLP-1 antagonist. Assessment of symptoms during a GE study may provide a useful biomarker for NUD in research and clinical practice.

Association Between Gastric Emptying Time and Incidence of Cardiovascular Diseases in Subjects With Diabetes.

Background/AimsDelayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms.MethodsAmong 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T½) and incidence of cardiovascular events following GES.ResultsThe mean age of subjects was 64.0 ± 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE (P = 0.015). Univariate analysis showed that GE T½ was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12–2.69; P = 0.014). In a multivariate model, association between GE T½ and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21–3.12; P = 0.006).ConclusionA delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms.

076 A rare case of anti-glutamate decarboxylase antibody syndrome presenting with recurrent vomiting

IntroductionAnti-glutamte decarboxylase antibody (anti-GAD) has been linked with various neurological syndromes including stiff-person syndrome, limbic encephalopathy, cerebellar ataxia, eye movement disorders and epilepsy (collectively known as ‘anti-GAD positive neurological syndromes’).1 We describe a very atypical phenotypic presentation of anti-GAD syndrome with unexplained vomiting and weight loss.CaseA 46 years old lady with no past medical or family history of note, presented with 6 months history of severe headaches and recurrent attacks of episodic vomiting (4–6 episodes of multiple vomiting daily) with no identified precipitant and complete normality in between the episodes with no other associated symptoms. She reported 15 kg of unintentional weight loss. Neurological examination and investigations including MRI brain, CT angiogram and liver enzymes, immunoglobulins, thyroid function, vasculitic screen were normal. Upper GI endoscopy, gastric emptying studies, CT imaging of chest, abdomen and pelvis and whole body PET scan were unremarkable. Serum autoimmune antibody screen was positive with high titre of anti-GAD antibody (1200 kU/liter). The cerebrospinal fluid anti-GAD antibody titre was raised at 103.7 kU/liter with otherwise normal parameters including negative oligoclonal bands. The nerve conduction studies did not show continuous motor activity or spasmodic reflex myoclonus (seen in stiff-person syndrome).2 A therapeutic trial of immunosuppression was introduced with moderate improvement in symptoms.ConclusionAnti-GAD neurological syndromes are rare and this is a unique presentation of the same. It is not completely understood why the presence of one antibody causes varied syndromes. The hypothesis is that the recurrent vomiting is possibly due to diaphragmatic spasms.ReferencesSaiz A, Blanco Y, Sabater L, et al. Spectrum of neurological syndromes associated with glutamic acid decarboxylase antibodies: diagnostic clues for this association. Brain 2008;131:2553–2563.Buechner S, Florio I, Capone L. Stiff person syndrome: A rare neurological disorder, heterogeneous in clinical presentation and not easy to treat. Case Rep Neurol Med2015; 2015:278065.

Solid-Meal Gastric Emptying Study.

The gastric emptying study provides a comprehensive assessment of gastric function and motility using a standardized meal-and-imaging protocol. View this table: TABLE 1 Medications to Discontinue 48–72 h Before Gastric Emptying Scintigraphy ([1][1],[3][2]) View this table: TABLE 2

Epidemiology and Diagnosis of Gastroparesis in the United States: A Population-based Study.

Goals:We aimed to establish the epidemiological characteristics and documentation of diagnostic workup for gastroparesis (GP).Background:No study has used a national database to evaluate the prevalence, demographics, and associated comorbid conditions of GP, and document rates of proper diagnosis.Materials and Methods:This was a cross-sectional population-based study using the Explorys Platform to determine the prevalence of GP in a large and diverse population highly representative of the US population and to examine the diagnostic approach of GP. Data collected were individual characteristics from electronic medical records (EMRs) included age, ethnicity/race, sex, diagnostic report for esophagogastroduodenoscopy (EGD) and gastric emptying study (GES).Results:A total of 43,827,910 medical records were surveyed (1999 to 2014), of which 69,950 had a diagnosis of GP, yielding an overall prevalence of 0.16%. We identified 249,930 EMRs with type 1 diabetes mellitus (T1DM), and 2,940,280 EMR’s with type 2 diabetes mellitus (T2DM), of which 11,470 (4.59%) and 38,670 (1.31%) EMR’s had concurrent GP, respectively. The remainder 19,810 EMRs with a diagnosis of GP were classified as having idiopathic GP. In all three subgroups, women and Caucasians had the highest prevalence of GP. The diagnosis of GP was confirmed by both GES and EGD in 9,950 of patients (14.22%). For patients with T1DM, T2DM, or idiopathic GP, GP was confirmed by both diagnostic tests in 16.8%, 14.0%, and 13.2%, respectively.Conclusions:Our estimated rates of prevalence of GP in T1DM and T2DM indicate that GP is not a common clinical complication in these populations. Majority of EMRs that indicated a diagnosis of GP did not include any documentation of definitive diagnostic testing (EGD and/or GES).

A Combination of Delayed Gastric Emptying and Gastroesophageal Reflux Disease is Associated with Worse Outcomes in Lung Transplantation

Purpose Gastroparesis and GERD are very common conditions in patients with end-stage lung disease and can be exacerbated after lung transplantation (LTx). At our center, we routinely test lung transplant recipients (LTRs) for gastric emptying abnormalities and for GERD at 3 months post-transplant. We hypothesized that LTRs with significant gastroparesis and/or GERD are more likely to develop lung injury leading to subsequent CLAD and death. Methods Among 2812 LTRs transplanted at our center between May 1998 and April 2018, we retrospectively analyzed 1071 patients who had a solid gastric emptying study available within seven months post-transplantation. Delayed gastric emptying (DGE) was defined as > 10% gastric retention at four hours and classified based on severity: mild (10-15%), moderate (16 - 35%), and severe (>35%). We obtained routine 24h pH/impedance testing in LTRs from 2004-2015, where GERD was defined as > 48 episodes of acid or non-acid reflux. 295 patients had both gastric emptying and reflux testing available. Cox proportional hazards models were used to determine the association between DGE, GERD, and combined DGE(moderate/severe)+GERD with time to CLAD or death. Results Mild, moderate, and severe DGE was found in 128 (12%), 163 (15.2%), and 302 (28.2%) patients, respectively. DGE alone was not associated with CLAD or death (HR 0.87 [95% CI 0.64-1.19]; HR 1.06 [95% CI 0.81-1.39]; HR 1.07 [95% CI 0.86-1.35]) for mild, moderate, severe, respectively (Figure 1A). Similarly, evidence of GERD alone was not associated with CLAD or death (abstract ISHLT 2017). However, the combination of moderate-severe DGE and GERD was significantly associated with death (HR: 1.81 [95% CI 1.07-3.05]). Conclusion In a single-center lung transplant cohort study , we observed that while DGE or GERD alone are not individually associated with CLAD or death, patients with both moderate-severe DGE and significant GERD had significantly worse survival.

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis

BackgroundPost-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP. MethodsPatients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded. ResultsDuring the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m2 and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging. ConclusionPOP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.

A comparison of the diagnosis of gastroparesis in 4\u2009h pediatric gastric emptying studies versus 2\u2009h studies

BackgroundIn adults, there is a consensus for standards to diagnose gastroparesis utilizing a gastric emptying study as the key diagnostic modality but there is no consensus for a standard in pediatrics. Additionally, some cost savings might be achieved if symptoms could be utilized to predict patients with gastroparesis. The aims of the current study were to confirm the sensitivity of a 4 h study in the pediatric population and to assess whether the severity of symptoms were predictive of delayed gastric emptying.StudyThis was a single site, two part study. In the first part, results were reviewed for all patients who had completed a 4-h, solid gastric emptying study over the course of a 3 year period. In the second portion of the study, participants scheduled for a gastric emptying study, completed a modified GCSI questionnaire.ResultsOut of a total of 109 participants, at 2 h, 14 participants (12.8%) had abnormal studies as compared to 26 (23.85%) participants who had abnormal studies at 4 h (p = .0027). Of the 95 participants with normal studies at 2 h, 15% (14/95) were abnormal at 4 h. There were no differences in symptom severity scores between those with slow and those with normal emptying at either 2 h or 4 h.ConclusionsOur study adds independent confirmation that extending studies from 2 to 4 h increases the diagnostic yield and should be the standard in children and adolescents as it is in adults.

Prevalence and Natural History of Barrett’s Esophagus in Lung Transplant: A Single-Center Experience

Barrett's esophagus (BE)-intestinal metaplasia in the esophagus-may progress to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and ultimately, invasive esophageal adenocarcinoma (EAC). The course of BE in immunosuppressed lung transplant recipients is unknown. This study retrospectively reviewed the records of patients who underwent lung transplant at asingle center, Norton Thoracic Institutein Phoenix, Arizona, between January 1, 2010 andOctober 31, 2016. Pretransplant esophagram, esophagogastroduodenoscopy, 24-hour pH monitoring, high-resolution manometry, and gastric emptying studies were analyzed. Of the 466 patients who underwent lung transplant during the study period, 54 (11.59%) had BEon pretransplant esophagogastroduodenoscopy. Of these, 1 patient had HGD before lung transplant. The median age of patients was 64 years (interquartile range, 58.25 to 68.75 years); 66.7% were men. Median follow-up duration was 29.48 months (interquartile range, 19.69 to 37.98 months). Sixteen of 54 patients (29.62%) underwent antireflux surgery after lung transplant. LGD or EAC developed in 3 patients during posttransplant surveillance. One patient had a diagnosis of HGD 24 months after retransplant. Sheunderwent complete endoscopic ablation and was dysplasia-free for 5 months, but ultimately the condition recurred, and she underwent esophagectomy for invasive cancer. Two patients had a diagnosis of LGD 7 and 13 months after lung transplant and were successfully treated with radiofrequency ablation. The rate of progression to dysplasia or EAC was 2.3% per patient-year. BE seems to be more prevalent in lung transplant recipients than in the general population. The study findings suggest that patients with BE have a higher risk of BE-to-EAC progression after lung transplant and that HGD may progress rapidly in immunosuppressed patients. More intensive surveillance endoscopy may be required in patients with BE after lung transplant.