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- Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. [JOURNAL ARTICLE]
- Aliment Pharmacol Ther 2014 Dec 19.
Pyloric pressure and compliance have never been investigated in health nor gastroparesis.We hypothesised that pyloric pressure and/or compliance may be altered in gastroparesis.Fasting pyloric pressure and compliance were investigated in 21 healthy volunteers (HV), 27 gastroparetic patients (GP) and 5 patients who had undergone oesophagectomy without pyloroplasty as positive controls. Under videofluoroscopic control, pyloric compliance and pressure were measured by the EndoFLIP technique. Gastric emptying half time (T1/2 ) using (13) C-octanoic acid breath test, as well as symptoms and quality of life (GIQLI score) were also monitored.Mean fasting pyloric compliance was measured at 25.2 ± 2.4 mm²/mmHg in HV, and was lower both in GP (16.9 ± 2.1 mm²/mmHg; P < 0.05) and patients with oesophagectomy (10.9 ± 2.9 mm²/mmHg; P < 0.05). By contrast, fasting pyloric pressure was not different among groups. Fasting pyloric compliance and pressure correlated with T1/2 in GP (R = -0.43; P = 0.04). Fasting pyloric compliance, but not pressure, correlated with symptoms and GIQLI score. Pyloric dilation in 10 GP with low fasting pyloric compliance (<10 mm²/mmHg) increased compliance from 7.4 ± 0.4 to 20.1 ± 4.9 mm²/mmHg (P < 0.01) and improved the GIQLI score from 72.5 ± 5.5 to 89.3 ± 6.1 (P = 0.04).This prospective study assessed pyloric compliance for the first time, and showed that fasting pyloric compliance is decreased in gastroparetic patients and is associated with T1/2 , symptoms and quality of life. This suggests that pyloric compliance may be a new relevant metric in gastroparetic patients, and may be useful to target patients for pyloric dilation or botulinum toxin injection.
- Duodenal rather than antral motility contractile parameters correlate with symptom severity in gastroparesis patients. [JOURNAL ARTICLE]
- Neurogastroenterol Motil 2014 Dec 17.
Studies of symptomatic gastroparetics consistently find poor correlation with gastric emptying. We hypothesized that concomitant small bowel dysmotility may play a role in symptom causation in gastroparesis and sought to test this hypothesis by using wireless motility capsule (WMC) testing to simultaneously measure antral and duodenal area under pressure curve (AUC) in patients with delayed gastric emptying.Using a cohort from a multicenter clinical trial and a separate tertiary clinical database, we identified gastroparetics that underwent concurrent WMC testing and completed the Gastroparesis Cardinal Symptom Index, a validated questionnaire. Our study included 35 gastroparetics defined by a gastric emptying time (GET) ≥5 h. Antral and duodenal AUC were assessed at 1-h windows pre-GET and post-GET, respectively.We found moderate correlations between duodenal AUC and symptom severity in the combined cohort (n = 35; R = -0.42; p = 0.01; 95% CI -0.7, -0.1). Removing patients with colonic delay resulted in a stronger correlation of duodenal AUC to symptom severity (n = 21; R = -0.63; p < 0.01; 95% CI -0.81, -0.31). The multicenter trial (n = 20) and clinical practice cohorts (n = 15) had significantly different symptom severity and exclusion criteria. When analyzed separately, significant correlations between duodenal AUC and symptom severity were observed (R = -0.71; p < 0.01; 95% CI -0.9, -0.4 and R = -0.72; p < 0.01; 95% CI -0.9, -0.3, respectively). Symptom severity and antral motility showed no correlation.We found significant correlations between duodenal AUC and symptom severity in two cohorts of gastroparetics. Small bowel motility may contribute to symptom generation in gastroparetic patients and this may inform therapeutic considerations.
- [Observation on therapeutic effects of acupoint injection of metoclopramide for postsurgical gastroparesis syndrome]. [English Abstract, Journal Article]
- Zhen Ci Yan Jiu 2014 Oct; 39(5):406-9.
To observe the clinical effects of acupoint injection of metoclopramide for postsurgical gastroparesis syndrome (PGS).A total of 46 patients with PGS(from abdominal surgery) were randomly divided into control and acupoint injection groups (n=23 in each group). Patients of the acupoint injection group were treated by injection of Metoclopramide (5 mg+ normal saline) into bilateral Zusanli (ST 36) and Weishu (BL 21) alternatively, while patients of the control group treated by injection of 10 mg of Metoclopramide into the deltoid muscle and gluteus maximus muscle alternatively. The treatment of both groups was conducted once daily for 14 days. A 3-point scale of clinical symptoms (abdominal distension, belching, nausea-vomiting, upper-abdominal distending pain, sour regurgitation and gastric burning sensation) was used to evaluate the therapeutic effect.There were no statistical differences between two groups in clinical symptom scores before the treatment (P>0.05). Following treatment, the clinical symptom scores of both groups were significantly decreased in comparison with pre-treatment (P<0.05) and the scores of the acupoint injection group were significantly lower than those of the control group (P<0.05). Of the 23 PGS patients in the control group and acupoint injection group, 0 and 2 were cured, 5 and 10 were significantly improved, 10 and 9 were improved, 8 and 2 failed, with the effective rates being 65.22% and 91.30%, respectively.Acupoint injection of Metoclopramide is effective for improving clinical symptoms of PGS patients.
- Totally minimally invasive Ivor-Lewis esophagectomy with single-utility incision video-assisted thoracoscopic surgery for treatment of mid-lower esophageal cancer. [JOURNAL ARTICLE]
- Dis Esophagus 2014 Dec 17.
The study aims to evaluate the safety and availability of totally minimally invasive Ivor-Lewis esophagectomy (MIIE) with single-utility incision video-assisted thoracoscopic surgery. Forty-one patients with mid-lower thoracic esophageal cancer were prospectively treated with totally MIIE. Two stages of laparoscopic-thoracoscopic procedures were performed. The first 29 patients were treated with four-port video-assisted thoracoscopic surgery (Group 1); the others were treated with single-utility incision video-assisted thoracoscopic surgery (Group 2). Short-term clinicopathological outcomes were examined. All patients had negative tumor margins and were pathologically staged from T1N0M0 to T3N2M0. Among Group 1, there was one conversion to open surgery. The mean duration of surgery was 268.4 ± 37.8 minutes, and mean blood loss was 207.2 ± 74.1 mL without significant differences between groups. The average thoracic or abdominal lymph node yield was 12.6 ± 7.1 or 6 ± 5.8, respectively. The median postoperative hospital stay was 7 days. No mortalities occurred. Minor morbidity complicated by late-stage gastroparesis occurred in two patients (4.9%) after discharge. Major morbidities, including intestinal obstruction and anastomotic leakage, occurred in three patients (7.3%) after discharge. Among Group 2, the average operative duration was 275.4 ± 31.2 minutes, and the mean blood loss was 220 ± 94.9 mL. One patient developed late-stage anastomotic leakage. The average thoracic or abdominal lymph node yield was 14.7 ± 8.8 and 6.3 ± 5.7, respectively. No statistically significant differences were identified between Group 1 and Group 2. MIIE with single-utility incision video-assisted thoracoscopic surgery is feasible in patients with mid-lower thoracic esophageal cancer without compromising the extent of surgical resection and perioperative outcomes.
- The drinking test: a current noninvasive technique to evaluate gastric accommodation and perception. [Journal Article]
- Acta Gastroenterol Belg 2014 Sep; 77(3):328-32.
Impaired gastric accommodation has been proposed as an im- portant mechanism in the generation of functional dyspepsia. There is an interest in methods that allow recording and quantifica- tion of the gastric accommodation reflex. Drinking tests, with water or nutrients, have been developed as a noninvasive, inexpensive method to assess gastric perception and accommodation. These tests are easily performed, do not need any special equipment and are well tolerated by patients. Drink test results are reported as the maximum tolerated volume, individual and cumulative symptom scores. Patients with functional dyspepsia have showed lower max- imum tolerated volumes than healthy volunteers. In these patients the maximum tolerated volume reflects the severity of early satiety and predicts impaired gastric accommodation, but it remains un- clear what physiologic processes are assessed by the drinking tests. Results of drinking tests may be influenced by physiologic factors, thus these results do not guide therapy. Given these facts, drinking tests are best reserved for clinical research purposes evaluating functional dyspeptic patients or patients with gastroparesis.
- Commentary on "cholecystectomy for biliary dyskinesia in gastroparesis: mimic or misfortune?". [Journal Article]
- South Med J 2014 Dec; 107(12):762-3.
- Cholecystectomy for biliary dyskinesia in gastroparesis: mimic or misfortune? [Journal Article]
- South Med J 2014 Dec; 107(12):757-61.
Biliary dyskinesia and gastroparesis are associated with upper abdominal discomfort and dyspeptic symptoms in the absence of structural abnormalities. We hypothesized that the similarity in symptoms would trigger testing and surgical treatment for biliary abnormalities in a significant number of patients, with refractory symptoms ultimately demonstrating impairment of gastric function.The study was designed as a retrospective review of patients seen between April 1, 2008 and December 31, 2009. Patients were identified using diagnosis code for gastroparesis (International Classification of Diseases, Ninth Revision code 536.3). Demographic information, duration, etiology and severity of disease, coexisting psychiatric illness, pain and functional gastrointestinal disorders, medication use, and abdominal surgery with a focus on cholecystectomy were abstracted from the medical records.A total of 131 patients were identified. Women predominated (77.86%), and the idiopathic form of gastroparesis was the most common etiology. A total of 59 (45%) patients had undergone cholecystectomies. Although symptomatic cholelithiasis was the primary indication, more than one-third of these patients underwent surgery for biliary dyskinesia (n = 19) or chronic acalculous cholecystitis (n = 2). In this subgroup, improvement was either absent (n = 13) or transient only (n = 8), lasting for 1.0 ± 0.6 months. Patients who underwent cholecystectomy were younger compared with the rest of the group; all other variables did not show significant differences.Considering the overlap and correlation between gastric and gallbladder function, we should raise the threshold for biliary dyskinesia and reassess the appropriateness of surgical therapy, especially in patients with coexisting dyspeptic symptoms.
- Gastroparesis as the initial presentation of pulmonary adenocarcinoma. [Journal Article]
- BMJ Case Rep 2014.
Malignancy-associated gastroparesis is an under-reported entity and its diagnosis as a cause of cachexia or gastrointestinal symptoms is often missed in clinical practice. This case report highlights an unusual association of pulmonary adenocarcinoma with gastroparesis at presentation. Malignancy-associated gastroparesis should be added to the differential diagnosis in patients presenting with delayed gastric emptying of unknown aetiology and should prompt further radiological investigations. Early detection and treatment of underlying gastroparesis in patients with cancer is necessary to improve the quality of life and to avoid premature clinical deterioration due to intolerance to oral treatment.
- Abnormal movements associated with oropharyngeal dysfunction in a child with Chiari I malformation. [JOURNAL ARTICLE]
- BMC Pediatr 2014 Dec 10; 14(1):294.
BackgroundChiari I malformations (CM I) are rare hindbrain herniations. Dysphagia and other oropharyngeal dysfunctions may be associated with CM I, but to our knowledge, no clinical presentation similar to ours has ever been reported. The purpose of this communication is to draw attention to a unique and atypical clinical presentation of a child with CM I.Case presentationA 7-year-old boy was evaluated for a two month history of atypical movements which would occur in the evening, and last for an hour after eating. These stereotypical movements with the head and chest bending forward and to the left side, accompanied by a grimace, were associated with sensation of breath locking without cyanosis. Pain and dysphagia were absent. The neurological examination was normal. The possibility of Sandifer syndrome posturing occurring with gastroesophageal reflux disease was considered but neither pain nor back hyperextension were associated with the atypical movements. Neither proton pump inhibitors (PPI) nor prokinetic agents improved his symptoms.Upper endoscopy and esophageal biopsy did not reveal eosinophilic esophagitis nor reflux esophagitis. Ear, throat and nose (ENT) exam was normal. A severe gastroparesis was demonstrated on milkscan study. Two 24 hour oesophageal pH probe studies pointed out severe gastroesophageal reflux (GER). High resolution manometric evaluation of the oesophagus revealed normal sphincter pressures and relaxations with no dysmotility of the esophageal body. Electroencephalography and polysomnography were normal. A brain magnetic resonance imaging (MRI) was performed and revealed a CM I: cerebellar tonsils extending to 12 mm, with syringomyelia (D4-D5).For a long period of time, the child¿s abnormal movements were considered to be nothing but tics and the CM I a fortuitous finding. Since the child remained symptomatic despite medical treatment, it was decided to proceed with surgery. One year after the onset of his symptoms. He underwent posterior fossa decompression with upper cervical laminectomy and expansion duroplasty. Postoperative MRI confirmed adequate decompression. His atypical posture and dyspnea completely resolved after surgery and he remains asymptomatic two years later.ConclusionChildren may have atypical presentations of CM I. Thus, CM I diagnosis should be considered in unexplained atypical oropharyngeal dysfunctions.
- Migraine associated with gastrointestinal disorders: review of the literature and clinical implications. [Journal Article, Review]
- Front Neurol 2014.:241.
Recent studies suggest that migraine may be associated with gastrointestinal (GI) disorders, including irritable bowel syndrome (IBS), inflammatory bowel syndrome, and celiac disease. Here, an overview of the associations between migraine and GI disorders is presented, as well as possible mechanistic links and clinical implications. People who regularly experience GI symptoms have a higher prevalence of headaches, with a stronger association with increasing headache frequency. Children with a mother with a history of migraine are more likely to have infantile colic. Children with migraine are more likely to have experienced infantile colic compared to controls. Several studies demonstrated significant associations between migraine and celiac disease, inflammatory bowel disease, and IBS. Possible underlying mechanisms of migraine and GI diseases could be increased gut permeability and inflammation. Therefore, it would be worthwhile to investigate these mechanisms further in migraine patients. These mechanisms also give a rationale to investigate the effects of the use of pre- and probiotics in migraine patients.