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- Management of Gastroparesis: Beyond Basics. [JOURNAL ARTICLE]
- Curr Treat Options Gastroenterol 2014 Sep 23.
Gastroparesis is defined as the presence of delayed gastric emptying in the absence of mechanical obstruction, with a variety of upper gastrointestinal symptoms. Although measurement of gastric emptying is necessary for the diagnostic labeling, this finding has little impact in terms of explaining the symptom pattern and determining the prognosis and therapeutic approach. Clinical management is based on ruling out of mechanical causes and serum electrolyte imbalances, followed by initial medical treatment with a gastroprokinetic agent in most cases. However, the evidence that these drugs provide substantial symptomatic benefit is weak. Recent attempts to establish efficacy with newer prokinetics, including serotonin-4, motilin, and ghrelin receptor agonists, have seen few successes, but a new group of agents is under evaluation. More recently, also, no benefit was found with treatment with a tricyclic antidepressant in idiopathic gastroparesis. In refractory cases, especially when there is weight loss, invasive therapeutics such as insertion of feeding tubes, intrapyloric injection of botulinum toxin, implantable gastric electrical stimulation, or surgical (partial) gastrectomy are occasionally considered, but there is little evidence of efficacy, and these are not devoid of potentially major complications. Gastroparesis is likely to remain a challenging condition in the clinic in the foreseeable future.
- [Early complications of intra-operative radiotherapy in locally advanced pancreatic cancer]. [English Abstract, Journal Article]
- Zhonghua Zhong Liu Za Zhi 2014 Jun; 36(6):473-5.
To investigate the complications in intra-operative radiotherapy (IORT) for patients with local advanced pancreatic cancer.The clinical data, operation material, overall dose of IORT, postoperative therapy, complications, treatment and prognosis were retrospectively analyzed in all the in-hospital pancreatic cancer patients from Nov 2008 to Jan 2012.There were 115 patients with local advanced pancreatic cancer treated with IORT in this study. 81 cases had a tumor in the head of pancreas and 34 cases in the pancreatic body and tail. The operation method was IORT combined with internal drainage surgery. The intra-operative radiotherapy was performed using Mobetron mobile electron accelerator, with a total dose of 12-20 Gy. Bilioenteric anastomosis and/or gastrointestinal anastomosis were included in the internal drainage surgery. Gastroparesis syndrome (10.4%), hemorrhage (3.5%), abdominal infection (2.6%), pancreatic fistula (0.9%) and renal failure (1.7%) were the common postoperative complication of IORT. All patients were cured except one who died of digestive tract hemorrhage.Major complications of IORT are gastroparesis syndrome, abdominal infection and hemorrhage. The incidence of gastroparesis syndrome is at the top of the list. However, early complications have a relatively better prognosis, indicating that IORT is a safe and reliable therapy for patients with locally advanced pancreatic cancer.
- Peroral endoscopic myotomy (POEM) for nutcracker esophagus. Three cases with 12 months follow-up. [JOURNAL ARTICLE]
- Scand J Gastroenterol 2014 Sep 16.:1-5.
Abstract Introduction. Peroral endoscopic myotomy (POEM) has been introduced as a new treatment of achalasia, and studies are emerging on POEM treatment of other esophageal motility disorders. The effects of medical treatment, botox injections and dilatations are often limited in patients with severe nutcracker esophagus (NE). We therefore decided to perform POEM in three patients with severe NE. Material and methods. Informed consent was provided. POEM was performed under general anesthesia on the distal esophagus and upper stomach. At 3 months, 6 months and 1 year postoperatively all patients had clinical follow-up, barium swallow and high-resolution manometry. Results. All patients displayed marked improvement with a significant reduction in Eckardt score at follow-up after 1 year, from 10, 10 and 11 to 3, 1 and 1, respectively. During follow-up, the patients were diagnosed with increased reflux index and one patient was diagnosed with gastroparesis. Conclusion. Considering our results, treating severe NE with POEM has to be considered in the future; however, further studies have to confirm this.
- Improved gastric emptying in diabetic rats by irbesartan via decreased serum leptin and ameliorated gastric microcirculation. [Journal Article]
- Genet Mol Res 2014; 13(3):7163-72.
Diabetic gastroparesis (DG) is a common clinical complication of diabetes mellitus. Leptin may cause delayed gastric emptying in the central and peripheral pathways. Microcirculatory disturbances in the stomach make gastric smooth muscles and nerves hypoxic-ischemic, thereby impairing gastric motility. Irbesartan is an angiotensin II (ATII) receptor blocker that indirectly decreases serum leptin levels and improves blood vessel endothelia. This study examined the effect of irbesartan on DG and its relationship with serum leptin levels and microcirculatory disturbances of the stomach. Sprague-Dawley rats were injected with streptozotocin to induce diabetes and were then treated with or without 0.012 g·kg(-1)·d(-1) irbesartan by gavage. After six weeks of treatment, the gastric evacuation rate (GER) was measured using phenol red. Serum leptin levels were detected using enzyme-linked immunosorbent assays. Endothelin (ET) in the stomach tissue was examined using a radioimmunoassay, whereas chemical colorimetry was used to measure the nitric oxide synthase (NOS) activity of stomach tissues. The mRNA expression of the ATII receptor (AT1R) was assessed using reverse transcription-polymerase chain reaction. Treatment with irbesartan significantly increased the GER of diabetic rats and reduced the serum leptin levels, as well as decreased the ET content and AT1R mRNA expression in the stomach (P < 0.05). Changes in the cNOS activity after irbesartan intervention were not significant (P > 0.05), whereas iNOS activity was significantly decreased (P < 0.05). Irbesartan can alleviate hyperglycemia-induced delayed gastric emptying, which is associated with decreased serum leptin levels and improved microcirculation in the stomach.
- [Diet improves symptoms of diabetic gastroparesis]. [News]
- MMW Fortschr Med 2014 Aug 21; 156(14):36.
- Endoscopic ultrasound comes of age: Mature, established, creative and here to stay! [Journal Article]
- Endosc Ultrasound 2014 Jul; 3(3):143-51.
Research in endoscopic ultrasound (EUS) is alive and kicking! This paper will present recent interesting developments in EUS based on research presented at the Digestive Disease Week (DDW) held in Chicago in 2014. Endosonographers are looking at various techniques to improve yield of fine needle aspiration and core biopsies, assess circulating tumor cells, apply EUS for personalized medicine and develop devices to ensure the adequacy of sampling. EUS may open new vistas in understanding of neurogastroenterology and gastrointestinal motility disorders as discussed in this paper. EUS guided drainage of pancreatic fluid collections, bile duct and gallbladder is feasible, and many randomized trials are being done to compare different techniques. EUS guided delivery of fiducials, drugs, coils or chemo loaded beads in possible. EUS has come off age, has matured and is here to stay! The DDW in 2014 in Chicago was a very active year for EUS. There were numerous papers on different aspects of EUS, some perfecting and improving old techniques, others dealing with randomized trials and many with novel concepts. In this paper, I will highlight some of the papers that were presented. It is not possible to discuss all the abstracts in detail. I have, therefore, chosen selected papers in different aspects of EUS to give the readers a flavor of the kind of research that was presented at DDW.
- Treatment of Functional Dyspepsia and Gastroparesis. [JOURNAL ARTICLE]
- Curr Treat Options Gastroenterol 2014 Aug 30.
Functional dyspepsia (FD) and gastroparesis (GP) are the two most prevalent gastric neuromuscular disorders. These disorders are frequently confused, have more similarities than differences, and can be thought of as two ends of a continuous spectrum of gastric neuromuscular disorders (Fig. 1). FD is currently defined by the Rome III criteria; it is now subdivided into a pain-predominant subtype (epigastric pain syndrome) and a meal-associated subtype (post-prandial distress syndrome). GP is defined by symptoms in conjunction with delayed gastric emptying in the absence of mechanical obstruction. Symptoms for both FD and GP are similar and include epigastric pain or discomfort, early satiety, bloating, and post-prandial nausea. Vomiting can occur with either diagnosis; it is typically more common in GP. A patient suspected of having either FD or GP should undergo upper endoscopy. In suspected FD, upper endoscopy is required to exclude an alternative organic cause for the patient's symptoms; however, most (70 %) patients with dyspeptic symptoms will have FD rather than an organic disorder. In suspected GP, upper endoscopy is required to rule out a mechanical obstruction. A 4-hour solid-phase gastric emptying scan is recommended to confirm the diagnosis of GP; its utility is unclear in patients with FD, as it may not change treatment. Once the diagnosis of FD or GP is made, treatment should focus on the predominant symptom. This is especially true in patients with GP, as accelerating gastric emptying with the use of prokinetics may not necessarily translate into an improvement in symptoms. Unfortunately, no medication is currently approved for the treatment of FD and, thus, technically, all treatment options remain off-label, including medications for visceral pain (e.g., tricyclic antidepressants) and nausea. This review focuses on treatment options for FD and GP with an emphasis on new advances in the field over the last several years.
- Macrophages in diabetic gastroparesis - the missing link? [JOURNAL ARTICLE]
- Neurogastroenterol Motil 2014 Aug 28.
Diabetic gastroparesis results in significant morbidity for patients and major economic burden for society. Treatment options for diabetic gastroparesis are currently directed at symptom control rather than the underlying disease and are limited. The pathophysiology of diabetic gastroparesis includes damage to intrinsic and extrinsic neurons, smooth muscle, and interstitial cells of Cajal (ICC). Oxidative damage in diabetes appears to be one of the primary insults involved in the pathogenesis of several complications of diabetes, including gastroparesis. Recent studies have highlighted the potential role of macrophages as key cellular elements in the pathogenesis of diabetic gastroparesis. Macrophages are important for both homeostasis and defense against a variety of pathogens. Heme oxygenase 1 (HO1), an enzyme expressed in a subset of macrophages has emerged as a major protective mechanism against oxidative stress. Activation of macrophages with high levels of HO1 expression protects against development of delayed gastric emptying in animal models of diabetes, while activation of macrophages that do not express HO1 are linked to neuromuscular cell injury. Targeting macrophages and HO1 may therefore be a therapeutic option in diabetic gastroparesis.This report briefly reviews the pathophysiology of diabetic gastroparesis with a focus on oxidative damage and how activation and polarization of different subtypes of macrophages in the muscularis propria determines development of delay in gastric emptying or protects against its development.
- Imparting knowledge & restoring hope. [Case Reports, Journal Article]
- JEMS 2014 Jul; 39(7):70-2.
- Medications associated with restless legs syndrome: a case-control study in the US Renal Data System (USRDS). [JOURNAL ARTICLE]
- Sleep Med 2014 Jun 13.
The objective of this study was to determine the association between the usage of four classes of "at-risk" medications (antidepressants, neuroleptics, antihistamines, and antiemetics with dopamine blockade) and restless legs syndrome (RLS) in dialysis patients within the United States Renal Data System (USRDS).This was a case-control design within a national (United States) patient registry of all patients with end-stage renal disease (ESRD) in the USRDS anytime during the period of 1 October 2006 to 31 December 2010, inclusive. A total of 16,165 ESRD patients (3234 cases; 12,931 age-, sex-, and race-matched controls) were studied.All four classes of "at-risk" medications see widespread use among patients in the USRDS. All were associated with increased odds of an RLS diagnosis (range of odds ratios, 1.47-2.28; all p < 0.0001) during the period of observation. Results were unchanged when controlling for time on hemodialysis. Usage of more than one class of medication increased the odds for having RLS.ESRD patients often receive medication intended for relief of conditions associated with their disease, such as depression and psychological issues, pruritus, and gastroparesis; however, such medications may increase the risk of RLS. Given the high prevalence of RLS in ESRD patients, these medications should only be used when their benefits clearly outweigh the risk of development of the troubling and distressing symptoms of RLS.