A middle-aged man presented at 4:00 with tense distended abdomen, severe pain and numb legs. His medical background included poorly controlled insulin-dependent diabetes. Abdominal x-ray showed a massively distended, featureless viscus on the left side of the abdomen thought to be a sigmoid volvulus. CT scan was delayed due to respiratory compromise from diaphragmatic splinting. Nasogastric and flatus tube decompression were attempted. Eventually CT was obtained and provisionally reported as a sigmoid volvulus. Emergency laparotomy was performed due to the risk of impending perforation. Operative findings were of a hugely distended stomach extending into the left iliac fossa almost completely occupying the abdominal cavity. Gastrotomy was used to decompress the stomach. No mechanical obstruction was identified. Postoperatively he had an episode of massive haematemesis thought to be due to sloughing of gastric mucosa. He was taken back to theatre and died on table.

Sarcina ventriculi is a Gram positive organism, which has been reported to be found rarely, in the gastric specimens of patients with gastroparesis. Only eight cases of Sarcina, isolated from gastric specimens have been reported so far. Sarcina has been implicated in the development of gastric ulcers, emphysematous gastritis and gastric perforation. We report a case of 73-year-old male, with history of prior Billroth II surgery and truncal vagotomy, who presented for further evaluation of iron deficiency anemia. An upper endoscopy revealed diffuse gastric erythema, along with retained food. Biopsies revealed marked inflammation with ulcer bed formation and presence of Sarcina organisms. The patient was treated with ciprofloxacin and metronidazole for 1 wk, and a repeat endoscopy showed improvement of erythema, along with clearance of Sarcina organisms. Review of reported cases including ours suggests that Sarcina is more frequently an innocent bystander rather than a pathogenic organism. However, given its association with life threatening illness in two reported cases, it may be prudent to treat with antibiotics and anti-ulcer therapy, until further understanding is achieved.

BACKGROUND:

Gastric emptying scintigraphy (GES) using a solid meal is often recommended for the evaluation of gastroparesis. However, some patients cannot tolerate the standardized egg-white sandwich (EWS) solid meal and an alternative meal is needed.

AIM:

The aim of this study was to compare GES, regional gastric emptying, and gastric contractility using a liquid nutrient meal (LNM; Ensure Plus(®)) to those using EWS.

METHODS:

Twenty healthy volunteers underwent GES using EWS and LNM on separate days. Gastric emptying was measured using scintigraphy and with a wireless motility capsule (WMC; SmartPill(®)).

RESULTS:

The gastric emptying half-time with LNM was similar to that with EWS (1.41 ± 0.11 vs 1.52 ± 0.08 h; P = 0.28) and the two were significantly correlated (r = 0.53; P = 0.017). There were time-related differences in gastric emptying of the LNM compared to EWS: in the first hour, gastric retention of EWS was slightly greater than that of LNM, whereas at 3 and 4 h, gastric retention of EWS was slightly less than that of LNM. Regionally, the percentage retention of the meal in the proximal stomach was greater for EWS than for LNM at 0.5 h. WMC gastric emptying times and gastric contractility for the two meals were not significantly different.

CONCLUSIONS:

Overall gastric emptying of the LNM was similar to that of the EWS meal. The LNM empties without a lag phase and takes slightly longer to empty from the distal stomach, likely due to its higher fat content. These differences are likely due to early accommodation with retention of solids in the proximal stomach and the need for trituration of solids. We conclude that this LNM can serve as an alternative to the conventional solid EWS for GES.

Diabetic gastroparesis is a common complication of diabetes, adversely affecting quality of life with symptoms of abdominal discomfort, nausea, and vomiting. The pathogenesis of this complex disorder is not well understood, involving abnormalities in the extrinsic and enteric nervous systems, interstitial cells of Cajal (ICCs), smooth muscles and immune cells. The ob/ob mouse model of obesity and diabetes develops delayed gastric emptying, providing an animal model for investigating how gastric smooth muscle dysfunction contributes to the pathophysiology of diabetic gastroparesis. Although ROCK2, MYPT1, and CPI-17 activities are reduced in intestinal motility disorders, their functioning has not been investigated in diabetic gastroparesis. We hypothesized that reduced expression and phosphorylation of the myosin light chain phosphatase (MLCP) inhibitory proteins MYPT1 and CPI-17 in ob/ob gastric antrum smooth muscles could contribute to the impaired antrum smooth muscle function of diabetic gastroparesis. Spontaneous and carbachol- and high K(+)-evoked contractions of gastric antrum smooth muscles from 7 to 12 week old male ob/ob mice were reduced compared to age- and strain-matched controls. There were no differences in spontaneous and agonist-evoked intracellular Ca(2+) transients and myosin light chain kinase expression. The F-actin:G-actin ratios were similar. Rho kinase 2 (ROCK2) expression was decreased at both ages. Basal and agonist-evoked MYPT1 and myosin light chain 20 phosphorylation, but not CPI-17 phosphorylation, was reduced compared to age-matched controls. These findings suggest that reduced MLCP inhibition due to decreased ROCK2 phosphorylation of MYPT1 in gastric antrum smooth muscles contributes to the antral dysmotility of diabetic gastroparesis.

Two-year follow-up of patients with diabetes mellitus (DM) nephropathy shows albuminuria reversal following angiotensin converting enzyme (ACE) inhibitors.To study about a clinical profile of 2-year follow-up of patients with DM nephropathy showing albuminuria reversal following ACE inhibitors.Twenty patients were taken up for study with duly informed consent and suggested for glycemic profile with HbA1C. Baseline renal function, urine microscopy, albuminuria, and other microvascular complications such as neuropathy and retinopathy. These patients were followed up for a period of 2 years with every month follow-up and monthly dose titration of ACE inhibitors, enalapril (Quote: Dr. M. K. Mani), to a maximum tolerable dose and checked after 1 week for raise in creatinine and potassium.Twenty patients, who have attended a secondary level diabetic clinic with diabetic nephropathy and are on regular follow-up for 2 years, were selected.Sick patients requiring parenteral feeds, IV antibiotics, co-morbid conditions such as autonomic gastroparesis and diabetic foot infections, type 1 diabetes and other known kidney disease, chronic kidney disease on dialysis are excluded from the study. EXPECTED RESULT: Reversal of albuminuria.Enalapril is a safe, cheaper ACE inhibitors and the good dose titration coupled with early screening for DM nephropathy really help in halting the progression of chronic kidney disease from DM nephropathy.

To study about the utility of goniometry in screening for limited joint mobility (LJM) in patients attending a secondary level Diabetic Clinic.Randomly selected data of 100 patients attending a secondary level diabetic clinic without any complications were used. Baseline neuropathy assessments, namely monofilament and biothesiometry were done. Range of movement around the ankle joint and 1(st) metatarsal joint was done using goniometry. Both the results were compared.Selected 100 patients attending a secondary level diabetic clinic and on regular follow-up were included in the study.Sick patients requiring parenteral feeds, IV antibiotics, co-morbid conditions such as microvascular complication, autonomic gastroparesis, and diabetic foot infections were excluded from the study.Goniometric screening for LJM is a cheap and effective screening tool for detecting early structural deformity producing a higher plantar pressure and ulcer, and thereby preventing them at early stage.

Soluble guanylate cyclase (sGC) is the principal target of nitric oxide (NO) to control gastrointestinal motility. The consequence on nitrergic signaling and gut motility of inducing a heme-free status of sGC, as induced by oxidative stress, was investigated.sGCβ1 (H105F) knock-in (apo-sGC) mice, which express heme-free sGC that has basal activity, but cannot be stimulated by NO, were generated.Diethylenetriamine NONOate did not increase sGC activity in gastrointestinal tissue of apo-sGC mice. Exogenous NO did not induce relaxation in fundic, jejunal and colonic strips, and pyloric rings of apo-sGC mice. The stomach was enlarged in apo-sGC mice with hypertrophy of the muscularis externa of the fundus and pylorus. In addition, gastric emptying and intestinal transit were delayed and whole-gut transit time was increased in the apo-sGC mice, while distal colonic transit time was maintained. The nitrergic relaxant responses to electrical field stimulation at 1-4 Hz were abolished in fundic and jejunal strips from apo-sGC mice, but in pyloric rings and colonic strips, only the response at 1 Hz was abolished, indicating the contribution of other transmitters than NO.The results indicate that the gastrointestinal consequences of switching from a native sGC to a heme-free sGC, which cannot be stimulated by NO, are most pronounced at the level of the stomach establishing a pivotal role of the activation of sGC by NO in normal gastric functioning. In addition, delayed intestinal transit was observed, indicating that nitrergic activation of sGC also plays a role in the lower gastrointestinal tract.

Background:

Gastroparesis is a disorder characterized by a delayed in gastric emptying of a meal in the absence of a mechanical gastric outlet obstruction. Idiopathic gastroparesis is at least as common as diabetic gastroparesis in most case series, and the true prevalence of gastroparesis is unknown.

Results:

We report here an interesting case of idiopathic gastroparesis characterized by a sudden onset in a female patient. Written informed consent for participation was obtained by participant. The diagnosis was confirmed by ultrasonographic study of gastric emptying and electrogastrography, by gastric endoscopy/histology, and finally by allergyic tests. The disorder was found to be due to a rare cause, namely anmatter like allergic predisposition. In factdetail, our patient, who demonstrated an allergy to gold salts, had drunk a glass of a liqueur consumed a drink containing gold flakes and developed an eosinophilic aggregation in the gastric mucosa observed at gastric endoscopy/histology. TheFinally, symptoms disappeared after steroid administration.

Conclusion:

Our experience suggests that a gastric histology and close enquiry into any a history of allergy may be useful diagnostic tools in cases of when idiopathic gastroparesis occurs.