Impaired Gastric Emptying Research Articles

Gastrointestinal Motility Disorders and Their Clinical Implications in Cirrhosis.

Gastrointestinal motility is impaired in a substantial proportion of patients with cirrhosis. Cirrhosis-related autonomic neuropathy, increased nitric oxide production, and gut hormonal changes have been implicated. Oesophageal dysmotility has been associated with increased frequency of abnormal gastro-oesophageal reflux. Impaired gastric emptying and accommodation may result in early satiety and may have an impact on the nutritional status of these patients. Small intestinal dysmotility might be implicated in small intestinal bacterial overgrowth and increased bacterial translocation. The latter has been implicated in the pathophysiology of hepatic encephalopathy and spontaneous bacterial peritonitis. Enhanced colonic motility is usually associated with the use of lactulose. Pharmacological interventions aiming to alter gastrointestinal motility in cirrhosis could potentially have a beneficial effect reducing the risk of hepatic decompensation and improving prognosis.

Surgical Treatment Results of Burn-Related Oesophageal Strictures.

Post-burn oesophageal stricture is a late complication, which may require surgical intervention. The aim of the study was to compare gastric and colonic conduits and to evaluate the safety, efficacy and complications of these techniques. Retrospective analysis of all patients treated for burn-related oesophageal strictures between 1989 and 2013. Oesophagectomy was performed via laparotomy and right thoracotomy, and/or cervical incision. Forty-six patients, including 29 men, aged 17-67years (mean: 41years), had burn-related oesophageal strictures. The post-operative follow-up period ranged between 3months and 30years. Colonic transposition was used in 23 patients. In 21 patients, the oesophageal substitute was introduced through the posterior mediastinum, and in two patients the retrosternal route was used. Gastric conduit in was used in 21 patients and jejunal interposition in one patient. One patient underwent segmental oesophageal resection with end-to-end anastomosis. One patient had necrosis of the colonic conduit with anastomotic leakage, two patients had oesophago-colonic anastomosis leakage, five developed anastomotic stenosis, and two had respiratory insufficiency. Among patients with a gastric conduit, anastomotic leakage occurred in four, cervical anastomotic stenosis occurred in two, and respiratory insufficiency occurred in three, and one patient had impaired gastric emptying that required surgical re-intervention. Operative mortality was three patients (6.5%). The use of colonic and gastric conduit is an effective and safe method for restoring the continuity of the gastrointestinal tract, with an acceptable rate of post-operative complications. Patients who undergo oesophageal resection for post-burn stricture require post-operative systematic endoscopic control.

Gastric ultrasound as a preoperative bedside test for residual gastric contents volume in children.

Emergency situations and conditions with impaired gastric emptying enhance the risk of perioperative pulmonary aspiration due to increased residual gastric contents volume (GCV). Gastric ultrasonographic (US) measurement of the gastric antral cross-sectional area (CSA) has been proposed to estimate preanesthetic GCV. However, only few healthy children and fasted pediatric patients have been investigated so far, predicting GCV with considerable imprecision. This study aimed to compare GCV assessed by US in different patient positions for measuring CSA, using magnetic resonance imaging (MRI) as reference, and to evaluate its potential as diagnostic test. Healthy volunteer children were examined in a crossover design on 2 days. After baseline examination, they received a light breakfast, followed by 7 ml·kg-1 clear fluid after 2 or 4 h. Gastric emptying was examined with MRI over 4 or 6 h, respectively. US was performed immediately after MRI in right lateral decubital (RLD) and supine with upper body elevated (SUBE) positions. Correlation coefficients (Pearson R; 95%CI) between CSA and body weight corrected GCV (GCVw ) as determined by MRI volumetry were calculated. Data are presented as median (range). Eighteen children aged 9.8 (6.8-12.2) years had 72 US examinations completed. CSA was 401 (101-1311) mm2 and 271 (118-582) mm2 , and R between CSA and GCVw was 0.76 (0.76-1) and 0.57 (0.41-0.88) for the RLD and SUBE positions, respectively. The corresponding GCVw was 2.1 (0.1-13.8) ml·kg-1 . A linear regression model from RLD was similar to one previously derived. Bland-Altman analysis and ROC plots are presented. CSA correlated with GCVw in healthy children over a wide range of gastric filling, with the RLD position clearly superior to the SUBE position, confirming a previously derived formula. Although direct calculation of GCVw is imprecise, this technique has the potential to become a diagnostic risk assessment test.

Small Intestine Obstruction in Patients due to Phytobezoar: Case Report of Four Patients

ABSTRACT Introduction: Bezoars are rare cause of small-bowel obstruction and lead to intraluminal obstruction. The other causes are foreign bodies, gall stones, and enteroliths. Phytobezoars are collection of non-digestible materials, usually of vegetable origin, and are most commonly found in patients with impaired gastric emptying, on high-fiber diet and with abnormal food habits.We present a case report of four patients who presented with acute intestinal obstruction, and the etiology in all these four cases was found to be a phytobezoar. The complaints of diffuse pain abdomen, vomiting, and constipation were common in all four cases. One patient had undergone a gastric pull-up surgery for carcinoma esophagus and one female had undergone bilroth1 for peptic ulcer disease. One patient was a known case of diabetes mellitus and had undergone surgery for perforated peptic ulcer few years back. Conclusion: Diagnosis of bezoars is usually confirmed by barium examination or endoscopy, and definitive treatment is surgery in case of obstruction with the removal of bezoar.

Central Exogenous Neuropeptide‐S Ameliorates Stress‐induced Impaired Gastric Emptying through Orexin‐mediated Pathway in Rats

Stress is widely believed to play a major role in developing functional gastrointestinal (GI) disorders. Acute restraint stress (ARS) stimulates corticotrophin releasing factor (CRF) in the amygdala and paraventricular nucleus (PVN) of the hypothalamus which in turn plays a dominant role to delay gastric emptying (GE) via peripheral autonomic neural pathways in rats. Neuropeptide‐S (NPS), composed of 20 amino acids, is the endogenous ligand for the NPS receptor (NPSR) which is highly conserved in vertebrates including human. Within central nervous system (CNS), the NPS‐producing neurons are found mainly in locus coeruleus (LC) and amygdala which is involved in coping with fear and stress. Activation of the hypothalamus by stress is likely to be mediated in part by amygdala, the key limbic structure involved in the stress‐induced effects on the GI functions. Furthermore, CRF has been shown to excite NPS neurons in LC through the CRF‐1 receptor. In rodents, centrally administered NPS has been shown to inhibit anxiety, stress behaviors and stress‐stimulated fecal output in the rats. Orexin‐A (OXA), a hypothalamic neuropeptide, regulates feeding activity, energy homeostasis and arousal. Orexin receptor type‐1 (OXR1) is highly expressed in the dorsal vagal motor nucleus and OXA was shown to stimulate postprandial gastric motor functions via central vagal pathways. On the other hand, it has been shown that centrally administered NPS activates orexin‐containing neurons in hypothalamus in rats suggesting that OXA may contribute to the NPS‐mediated alterations in gastric motor functions under stressed conditions. To perform neuropeptide microdialysis, a microdialysis probe with large pore membrane was unilaterally placed into the central amygdala and LC. Central administrations of the drugs were performed through an injection cannula stereotaxically placed in the right lateral ventricle. NPS concentrations in microdialysates were assayed using EIA method. Solid GE was measured following an overnight fasting. Compared to their basal levels, ARS significantly reduced the NPS concentrations both in LC (5564.8 ± 186.8 ng/ml vs 562.9 ± 86.8 ng/ml, p<0.01) and amygdala (5197.7 ± 217.1 ng/ml vs 91.8 ± 12.18 ng/ml, p<0.01). In control rats, GE was 61.2 ± 3.4%. ARS significantly delayed gastric emptying 24.4 ± 3.2%; whereas, central administration of NPS (8 nmol, icv) completely restored the delayed GE induced by ARS (62.5 ± 5.7%, p<0.01). Pretreatment of selective OXA antagonist SB‐334867 (40 μg, icv) significantly (p<0.05) abolished the NPS‐induced restoration of delayed GE (38.9 ± 2.7%, p<0.05). It is suggested that stress may alter NPS expression within CNS. Exogenous administration of NPS restores stress‐induced gastric dysmotility which was abolished by OXA antagonist, suggesting that the effect of NPS on stress‐induced gastric motility is partly OXA‐dependent. Central NPS may be a novel candidate for the treatment of stress‐induced gastric motility disorders.

Improvement of meal-related symptoms and epigastric pain in patients with functional dyspepsia treated with acotiamide was associated with acylated ghrelin levels in Japan.

The aim of this study is to clarify whether acotiamide and rabeprazole combination therapy can improve clinical symptoms, gastric emptying, and satisfaction with treatment in functional dyspepsia (FD) patients more effectively than acotiamide or rabeprazole monotherapy alone. We also aimed to determine whether acotiamide affects these changes via its effect on gastric emptying and appetite-related hormones such as ghrelin. We used Rome III criteria to evaluate upper abdominal symptoms and anxiety by the State-Trait Anxiety Inventory (STAI). Gastric motility was evaluated by the (13) C-acetate breath test. Eighty-one FD patients were treated with acotiamide (300 mg/day) (n = 35), acotiamide (300 mg/day) and rabeprazole (10 mg/day) (n = 28), or rabeprazole (10 mg/day) (n = 18) for a period of 4 weeks and followed after 4 weeks of no treatment. Adenocorticotropic hormone (ACTH), cortisol, leptin and ghrelin levels were measured in all FD patients. Acotiamide and rabeprazole combination therapy significantly improved postprandial distress syndrome (PDS)-like symptoms (p = 0.018, p = 0.04 and p = 0.041, respectively) and epigastric pain (p = 0.024) as wells as STAI-state scores (p = 0.04) compared to rabeprazole monotherapy. Both acotiamide monotherapy, and acotiamide taken in combination with rabeprazole, significantly (p = 0.001 and p = 0.02, respectively) improved satisfaction with treatment, compared to rabeprazole monotherapy. Acotiamide and rabeprazole combination therapy had no significant effect on ACTH and cortisol levels in FD patients. Of interest, acotiamide monotherapy, and acotiamide and rabeprazole combination therapy, significantly (p < 0.0001 and p = 0.018, respectively) increased acylated ghrelin/total ghrelin ratios and significantly (p = 0.04) improved impaired gastric emptying compared to rabeprazole monotherapy. Further studies are warranted to clarify how acotiamide treatment improves clinical symptoms in FD patients.

Large gastric wood bezoar: Anesthesia implications.

Sir, Bezoars are collections or concretions of indigestible foreign material that accumulate and coalesce in the gastrointestinal tract, most commonly in the stomach. Gastric bezoar formation occurs in patients with altered gastric physiology, impaired gastric emptying and other co-existing illness affecting gastrointestinal motility. It is also commonly seen in patients with psychiatric illnesses and history of pica. In the pediatric population, common types of bezoar seen are lactobezoars, phytobezoars, and trichobezoars.[1] We report the case of a 7-year-old child with a large gastric wood bezoar. A 7-year-old male child weighing 20 kg presented with a history of pica, mostly wooden scrapings since 2½ years, pain in abdomen and vomiting. Upper gastrointestinal (UGI) endoscopy revealed a large gastric bezoar. The patient underwent endoscopy twice during which general endotracheal anesthesia was given but the attempts to remove the bezoar piecemeal were unsuccessful. Five days following the third endoscopy, the patient developed constipation, abdominal tenderness and guarding, and was scheduled for a laparotomy. The biochemical investigations of the patient were normal, except for hemoglobin level of 92 g%. Preoperative optimization of fluid status was done. Rapid sequence induction (RSI) was done using 40 mg of propofol and 20 mg of rocuronium intravenously, and the patient was intubated using 5.5 mm ID cuffed endotracheal tube. A 24 G lumbar epidural catheter was inserted postinduction for analgesia. Gastric perforation was seen on laparotomy caused either by the bezoar itself or the attempted endoscopic removal. After extending the incision, a phytobezoar measuring 13 cm × 11 cm (200 g) was removed, and the gastric perforation was closed [Figure 1]. Anesthesia was reversed, and recovery was uneventful.Figure 1: Wood bezoarThe anesthesiologist must be aware of the perioperative complications of a large gastric bezoar. The complication rate of endoscopy is 0.1% for UGI procedures with cardiopulmonary events predominating (50%) which include dysrhythmias, hypoxemia from respiratory depression, and cardiac arrest. Bleeding, aspiration, and perforation are other complications.[2] There is a reported case of respiratory arrest due to airway obstruction following the endoscopic removal of trichobezoar.[2] Certain co-morbid conditions such as cystic fibrosis, diabetes mellitus, hypothyroidism, Guillain–Barre syndrome, and renal failure, etc., have been associated with an increased risk of bezoar formation.[3] Bezoars are also associated with failure to thrive and iron deficiency anemia. Patients with protracted obstructive symptoms and vomiting are likely to be hypovolemic and have electrolyte disturbances. Preprocedure resuscitation may be required. RSI is indicated as these patients are at high risk of aspiration.[4] In pediatric patients, the cricoid pressure given during RSI can distort the airway and interfere with smooth induction. Furthermore, there are more chances of hypoxemia in the period between induction and reestablishment of ventilation.[5] Hence, we avoided the “classic” RSI and used gentle pressure limited mask ventilation with 100% oxygen following induction. The close psychiatric follow-up is recommended to diminish the chances of recurrence.[1] Laparoscopic removal of gastric bezoar is associated with less postoperative morbidity and pain but is technically challenging.[3] Our patient had borderline hemoglobin with a picture of iron deficiency anemia with normal electrolytes. The risk of aspiration was present as the patient had developed obstructive symptoms. Due to the large size of bezoar and risk of aspiration, RSI was done. As the patient was clinically stable, propofol was used for induction, and epidural anesthesia was also given. The patient was referred for psychiatric evaluation postoperatively. To conclude, the anesthetic plan to manage a gastric bezoar should include complications associated with preoperative fluid and electrolyte imbalance, the need for RSI and intubation, and issues associated with the procedure or surgery itself. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Short- and Long-Term Safety of PEG-J Used for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel

Introduction: Irregular drug plasma levels due to impaired gastric emptying may contribute to motor complications observed in patients with Parkinson's disease (PD) treated with oral medication. One treatment for PD uses percutaneous endoscopic gastrostomy with jejunal extension tube (PEGJ) to continuously deliver levodopa-carbidopa intestinal gel (LCIG, known in the US as carbidopa-levodopa enteral suspension [CLES]) directly to the jejunum for 16 hours, thereby bypassing the stomach and avoiding fluctuating drug plasma levels. We assessed short- and long-term safety of the PEG-J procedure and device used to deliver LCIG in mobile patients with PD from our most recent clinical trial data cut. Methods: All patients received a 15 French Freka PEG tube and a 9 French Freka jejunal extension tube, placed during the same endoscopy. The ideal jejunal tube tip position was distal to the ligament of Treitz. PEG-J procedure- and device-related treatment-emergent adverse events (AEs) reported during 4 phase 3 LCIG studies (including an ongoing open-label extension study into which all others filtered) were integrated and evaluated. AEs and serious AEs (SAEs) in patients treated with LCIG were included in this analysis at the March 2014 data cut-off date. Results: A total of 395 patients were included in this analysis. The median (range) exposure to PEG-J was 986 (1-1972) days; 165 patients were exposed for ≥1095 days, 130 patients were exposed for ≥1260 days, and 70 patients were exposed for ≥1460 days. The incidence of SAEs was highest in the first week and declined rapidly thereafter (Figure 1). Over the long-term, procedure/device-associated AEs occurred in 387 (94%) patients and SAEs occurred in 68 (17%) patients (Table 1), although single events may have been coded to >1 preferred term. Procedure/device-associated AEs led to discontinuation in 19 (4.8%) patients; those that led to discontinuation in >1 patient included complication of device insertion (10 patients; 2.5%), abdominal pain (4 patients, 1.0%), abdominal discomfort (2 patients, 0.5%), and peritonitis (2 patients, 0.5%).Figure 1Table 1: Overall Procedure/Device-associated Adverse EventsConclusion: The overall safety profile of LCIG via PEG-J is comparable to published data in immobile patients (Itkin M et al, Gastroenterology, 2011;141:742-65). Incidence of SAEs declined after the first week post-procedure. The low discontinuation rate of LCIG treatment via PEG-J demonstrates that this treatment can be maintained for long-term use in this mobile patient population with advanced PD.

Triple Lumen Nasojejunal Tube With Subsequent Decompression and Feeding: A Chinese General Hospital Experience

SignificanceHospitalized patients who cannot tolerate oral food intake may be susceptible to malnutrition. Enteral access is the foundation of enteral nutritional therapy. Enteral access allows nutrients and medications to be delivered in patients who cannot maintain an adequate oral intake. Gastrointestinal access can also be used for decompression in enteral obstruction.Clinical PresentationThere were 16 patients presented with gastric outlet obstruction either from tumor infiltration, or pre/postoperative nutritional build up, or severe gastroparesis.ManagementThe patients underwent nasojejunal tube insertion either through endoscopic fluoroscopic confirmation. Enzymatically hydrolysed whey protein (Peptamen) feeding was initated; decompression of the stomach was also simultaneously done. The patients’ nutrition and quality of life improved.RecommendationEnteral nutrition can be delivered using a nasogastric or a nasojejunal tube. Postpyloric feeding is indicated whenever nutritional intake is compromised because of impaired gastric emptying. There is still limited experience locally; it is suggested that endoscopist be familiar with various techniques of NJT insertion for nutritional built-up. SignificanceHospitalized patients who cannot tolerate oral food intake may be susceptible to malnutrition. Enteral access is the foundation of enteral nutritional therapy. Enteral access allows nutrients and medications to be delivered in patients who cannot maintain an adequate oral intake. Gastrointestinal access can also be used for decompression in enteral obstruction. Hospitalized patients who cannot tolerate oral food intake may be susceptible to malnutrition. Enteral access is the foundation of enteral nutritional therapy. Enteral access allows nutrients and medications to be delivered in patients who cannot maintain an adequate oral intake. Gastrointestinal access can also be used for decompression in enteral obstruction. Clinical PresentationThere were 16 patients presented with gastric outlet obstruction either from tumor infiltration, or pre/postoperative nutritional build up, or severe gastroparesis. There were 16 patients presented with gastric outlet obstruction either from tumor infiltration, or pre/postoperative nutritional build up, or severe gastroparesis. ManagementThe patients underwent nasojejunal tube insertion either through endoscopic fluoroscopic confirmation. Enzymatically hydrolysed whey protein (Peptamen) feeding was initated; decompression of the stomach was also simultaneously done. The patients’ nutrition and quality of life improved. The patients underwent nasojejunal tube insertion either through endoscopic fluoroscopic confirmation. Enzymatically hydrolysed whey protein (Peptamen) feeding was initated; decompression of the stomach was also simultaneously done. The patients’ nutrition and quality of life improved. RecommendationEnteral nutrition can be delivered using a nasogastric or a nasojejunal tube. Postpyloric feeding is indicated whenever nutritional intake is compromised because of impaired gastric emptying. There is still limited experience locally; it is suggested that endoscopist be familiar with various techniques of NJT insertion for nutritional built-up. Enteral nutrition can be delivered using a nasogastric or a nasojejunal tube. Postpyloric feeding is indicated whenever nutritional intake is compromised because of impaired gastric emptying. There is still limited experience locally; it is suggested that endoscopist be familiar with various techniques of NJT insertion for nutritional built-up.

Acetaminophen Absorption Kinetics in Altered Gastric Emptying: Establishing a Relevant Pharmacokinetic Surrogate Using Published Data

ABSTRACTAcetaminophen has been used as a tool for clinical and nonclinical experimental designs that evaluate gastric emptying because acetaminophen is not absorbed in stomach but efficiently absorbed from the small intestine. Published pharmacokinetic data of acetaminophen in subjects with normal gastric emptying vs. impaired gastric emptying (i.e., morphine treatment) were evaluated to select a key surrogate. Using Caverage (average concentration), computed from the exposure within the first hour, individual rank distribution was plotted across different studies. Caverage was highly correlated with Cmax (maximum concentration) in subjects with normal gastric emptying (R2 = .7532) but not in those where gastric emptying was impaired (R2 = .0213). The 50th percentile value of the distribution pattern of 1/Caverage in acetaminophen+morphine-treated group (coincided with the first shift in the slope) was considered as the cutoff point to figure out the impaired gastric emptying. The individual rank distribution plots for 1/Caverage across different studies supported similar trends in subjects with normal gastric emptying but showed a distinct distribution pattern in the cohort of impaired gastric emptying. Caverage, calculated within the first hour of dosing of acetaminophen (average concentration at 0–1 hour, C0–1havg), can be used as a key surrogate to distinguish the effects of gastric emptying on the absorption of acetaminophen. A 4 μg/mL C0-1havg of acetaminophen (dose: 1.5 g) may be used as cutoff point in future clinical investigations of acetaminophen to clarify the role of gastric emptying.

Outpatient vs. Inpatient Gastric Emptying Studies: Does Admission Status Influence Findings?

Objectives: Gastric emptying studies are performed in both outpatient and inpatient settings. Although there is no data on the prevalence of positive and negative testing between inpatient and outpatient studies, some feel inpatient testing is inappropriate secondary to potential false positives. We aim to identify the incidence and determinants of abnormal studies for inpatient versus outpatient gastric emptying studies. Methods: A retrospective chart review of scintigraphic gastric emptying studies was performed between June 1, 2012 and April 11, 2014. Demographics, clinical information, and procedure details were collected. Descriptive statistics were used to report findings with categorical variables analyzed using Pearson Chi-Square test and continuous variables analyzed with independent samples t-test. All statistical analyses were performed using IBM SPSS Statistics version 21.0 software. Results: 107 GE studies were reviewed (34 inpatient, 73 outpatient). Six incomplete studies were excluded. Mean patient age was 51 years (64% female, 60% Caucasian). There were more women than men in the outpatient population (p=0.04). The inpatient studies had a higher percentage of African Americans while the outpatient studies were mostly Caucasian (p=0.002). There were no other demographic differences between the inpatient and outpatient groups. The most common indication for testing was nausea and/or vomiting (44%). 42 (22 inpatient, 20 outpatient) tests were positive and 59 (8 inpatient, 51 outpatient) were negative for impaired gastric emptying. Inpatient GE testing was abnormal 73% of the time, while outpatient GE testing was abnormal 28% of the time (p<0.01). Review of inpatient GE studies revealed 97% patients received a medication known to alter gastric motility and 67% received opioid narcotics within 72 hours of testing. Patients with diabetes were 2.28 times more likely to have a positive test than patients without diabetes. Half of the abnormal tests were found in patients with diabetes. Conclusions: Abnormal gastric emptying studies are more commonly found in inpatient studies. A majority of inpatient studies are performed on patients who have received medications known to delay gastric motility and may be at an increased risk for false positives.

Upside Down Intrathoracic Stomach: A Case Report

Introduction: A 73-year-old male with a history of hiatal hernia and short-segment Barrett’s esophagus presented with complaints of nausea, vomiting, and acute, stabbing abdominal pain thirty minutes after eating. He also endorsed the sensation of food being stuck in his chest, but no hematemesis, melena, odynophagia, weight loss, fevers, or chills. On exam, vitals were within normal limits, abdomen was soft, non-distended, and tender to palpation in the upper epigastrium without rebound or rigidity. Cardiopulmonary exam was unremarkable. Laboratory studies revealed lactate of 3.32 mmol/L (ref 0.6-2.3 mmol/L) and lipase of 107 U/L (10-73 U/L). Further evaluation with CT abdomen revealed a very large hiatal hernia with an upside down intrathoracic stomach that was mildly to moderately distended and worrisome for delayed gastric emptying. He was admitted to the hospital, maintained nothing per os (NPO), and given intravenous fluids. Thoracic Surgery was consulted and performed thoracotomy with Belsey Mark IV fundoplication for gastric outlet obstruction secondary to the large intrathoracic stomach. At one month post-surgery, he was tolerating meals and doing well. Upside down stomach is a rare form of hiatal hernia (<5%) characterized by migration of the gastroesophageal junction and stomach into the mediastinum. It is considered to be a type 3 hiatal hernia with both a sliding and paraesophageal component. A common clinical manifestation is post-prandial distress, however patients may also experience post-prandial fullness, nausea, and vomiting as well as substernal pain, heartburn, and dysphagia. Symptoms are mainly related to impaired gastric emptying due to mechanical obstruction. Complications include incarceration, volvulus development, and severe gastric bleeding. Once diagnosed, upside down stomach should be repaired surgically with relocation of the stomach, excision of the hernia sac, repair of the hiatal defect, and an anti-reflux procedure.Figure 1

Sa1629 Gastrointestinal Safety & Device Longevity of Long-Term PEG-J Used for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel

Motor complications observed in patients with advanced Parkinson's disease (PD) on oral medications might be due to impaired gastric emptying and fluctuating drug plasma levels. A novel treatment for PD involves the use of a percutaneous endoscopic gastrostomy with jejunal extension tube (PEG-J) to provide continuous delivery of levodopa-carbidopa intestinal gel (LCIG) directly to the jejunum.

Effect of prolonged general anesthesia with sevoflurane and laparoscopic surgery on gastric and small bowel propulsive motility and pH in dogs

ObjectiveTo determine if general anesthesia with sevoflurane and laparoscopic surgery changed gastric and small bowel propulsive motility or pH in dogs. Study designProspective, controlled trial. AnimalsTwelve, 19–24 months old, female, Treeing Walker Hound dogs, weighing 23–30 kg. MethodsDogs were anesthetized for a median of 8.5 hours during another study to determine the minimum alveolar concentration of sevoflurane using a visceral stimulus. Gastric and small bowel motility were determined using a sensor capsule that measures pressure, pH and temperature. Gastric transit time and motility index were calculated. For 8/12 dogs, gastric motility, pH and transit time were measured. In 4/12 dogs, small bowel motility and pH were measured. ResultsAnesthesia decreased gastric and small bowel motility but did not change luminal pH. Mean gastric contraction force decreased from median (range) 11 (8–20) to 3 (1–10) mmHg (p < 0.01) and gastric motility index decreased from 0.63 (0–1.58) to 0 (0–0.31; p = 0.01). Frequency of contractions did not change, 3.7 (1.6–4.4) versus 2.8 (0.1–5.1) contractions minute−1 (p = 0.1). Gastric motility returned to normal 12–15 hours following anesthesia. Gastric emptying was prolonged from 12 (5.3–16) to 49 (9.75–56.25) hours (p < 0.01). Mean small bowel contraction force decreased from 34 (24–37) to 3 (0.9–17) mmHg (p < 0.02) and motility index decreased from 3.75 (1–4.56) to 0 (0–1.53; p = 0.02). Frequency of contractions did not change, 0.5 (0.3–1.4) versus 1.4 (0.3–4.6) contractions minute−1 (p = 0.11). Small bowel motility returned within 2 hours after anesthesia. Laparoscopy did not result in changes to gastric or small bowel parameters beyond those produced by general anesthesia. Conclusions and clinical relevanceThe force of gastric and small bowel contractions decreased during sevoflurane anesthesia for laparoscopy. Although gastric motility returned to normal within 12–15 hours the impairment of gastric emptying lasted 30–40 hours, predisposing dogs to postoperative ileus.

Management of acute upside-down stomach

BackgroundUpside-down stomach (UDS) is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. Symptoms may vary heavily as they are related to reflux and mechanically impaired gastric emptying. UDS is associated with a risk of incarceration and volvulus development which both might be complicated by acute gastric outlet obstruction, advanced ischemia, gastric bleeding and perforation.Case presentationA 32-year-old male presented with acute intolerant epigastralgia and anterior chest pain associated with acute onset of nausea and vomiting. He reported on a previous surgical intervention due to a hiatal hernia. Chest radiography and computer tomography showed an incarcerated UDS. After immediate esophago-gastroscopy, urgent laparoscopic reduction, repair with a 360° floppy Nissen fundoplication and insertion of a gradually absorbable GORE® BIO-A®-mesh was performed.ConclusionGiven the high risk of life-threatening complications of an incarcerated UDS as ischemia, gastric perforation or severe bleeding, emergent surgery is indicated. In stable patients with acute presentation of large paraesophageal hernia or UDS exhibiting acute mechanical gastric outlet obstruction, after esophago-gastroscopy laparoscopic reduction and hernia repair followed by an anti-reflux procedure is suggested. However, in cases of unstable patients open repair is the surgical method of choice. Here, we present an exceptionally challenging case of a young patient with a giant recurrent hiatal hernia becoming clinically manifest in an incarcerated UDS.

The Application of Electromagnetically Guided Post-pyloric Feeding Tube Placement in Critically Ill Patients

ABSTRACTBackground: Critically ill patients who demonstrate impaired gastric emptying benefit from post-pyloric enteral nutrition. However, correct placement of post-pyloric tube is challenging. Methods: In a retrospective, single center study, 142 critically ill patients were enrolled using electromagnetic technology. Our specialized team placed all post-pyloric tubes. Metoclopramide (10 mg) was infused 15 min prior to tube placement, and the tube tip location was confirmed by X-ray. Success rate for post-pyloric placement, implant time, time until EN initiation, and placement-related complications were measured. Results: 135 tubes in 142 patients were successfully placed during the first attempt, including 101 jejunal and 34 duodenal tubes. The average placement time was 20.12 min. The time from the physician order to the first tube placement attempt and EN administration was 3.6 and 7.5 hr, respectively. No placement-related complications were observed. Conclusions: Electromagnetic technology facilitates safe and effective post-pyloric feeding tube placement at the bedside in critically ill patients with impaired gastric emptying.

AB0635 Gastrointestinal quality of life index (GIQLI) in patients with primary sjÖgren’s syndrome

BackgroundPrimary Sjögren’s Syndrome (pSS) is a chronic, inflammatory autoimmune disorder, characterized by lymphocytic infiltration of the exocrine glands, leading to decrease of glandular secretion. Gastrointestinal (GI) involvement is reported to...

Determinants of impaired gastric emptying in type 2 diabetic patients

Although the harmful consequences of impared gastric motility are well-known, the determinants of this complication in type 2 diabetes (DM) are not clearly evidenced. The aim of this study was to recognize the factors which affect gastric emptying in patients (pts) with type 2 DM. Patients, methods: 31 pts with type 2 DM were included (duration of DM: 14.4 ± 1.7yrs; BMI: 29.5 ± 1; age: 60.2 ± 1.7; mean ± SE) Scintigraphic procedure was applied to evaluate the stomach emptying. Autonomic neuropathy (AN) was assessed by cardiovascular reflex tests. The symptoms were analyzed with a questionnaire. Results: The half time of gastric emptying (T1/2) significantly correlated with the age of the pts (T1/2-age: r = 0.39, p < 0.05). Significant relationship was also found betweeen abnormal gastric emptying and the degree of autonomic dysfunction (T1/2-AN score: r = 0.40, p < 0.05. HbA1c, BMI, diabetes duration or the severity of digestive symptoms did not correlate the stomach motility. More delayed gastric emptying was established in insulin-treated type 2 DM pts (T1/2: 84 ± 9 vs. 62 ± 7 min, p < 0.05; insulin-treated vs. non insulin-treated pts) in the presence with a more severe AN (AN score: 6.9 vs. 3.4, p < 0.001; insulin-treated vs. non insulin-treated pts) Conclusions: HbA1c, BMI, diabetes duration or symptoms do not predict the impaired gastric function in type 2 diabetes. A delayed gastric emptying might be expected in elder patients with autonomic neuropathy. Patients with insulin treatment have seriously impaired autonomic function and gastric dysmotility in type 2 diabetes. Our data support a possible particular role of autonomic neuropathy in the complex pathophysiology of impaired gastric emptying in type 2 diabetes.

Is there a difference in gastric emptying between myotonic dystrophy type 1 patients with and without gastrointestinal symptoms?

Gastrointestinal symptoms are frequent complaints in patients with myotonic dystrophy type 1 (MyD1) and may be associated with reduced gastrointestinal motility caused by smooth muscle dysfunction. Although previous studies have found delayed gastric emptying (GE) in MyD1 patients, the relationship between GE and symptoms has been unclear. We investigated GE in 23 MyD1 patients and 20 healthy volunteers using the 13C-acetate breath test. The MyD1 patients were divided into two groups: those with gastrointestinal symptoms (n = 9) and those without gastrointestinal symptoms (n = 14). The GE function was estimated using the 13C-acetate breath test as half-emptying time (HET) and peak time of the 13C-%-dose-excess curve (T max). GE (HET and T max) was more significantly delayed in patients with MyD1 than in the controls. The GE in MyD1 patients with gastrointestinal symptoms was significantly delayed compared to those without gastrointestinal symptoms. The GE in MyD1 patients with gastrointestinal symptoms was more significantly delayed than in the controls. The GE was significantly delayed in MyD1 patients with gastrointestinal symptoms for >5 years as compared to those with the disease for <5 years, while GE of MyD1 patients without gastrointestinal symptoms did not correlate with the duration of the disease. The GE in MyD1 patients did not correlate with the muscular disability rating scale. These findings suggest that impairment of GE evolves over time and that the progression of delayed GE and skeletal muscle impairment are independent. Smooth muscle impairment may be affected at an earlier stage in MyD1.

Letters to the Editor The giant in the stomach – trichobezoar

Letters to the Editor The giant in the stomach – trichobezoar