-
Gastroenterology Jan 2022Gastroparesis is characterized by symptoms suggestive of, and objective evidence of, delayed gastric emptying in the absence of mechanical obstruction. This review... (Review)
Review
Gastroparesis is characterized by symptoms suggestive of, and objective evidence of, delayed gastric emptying in the absence of mechanical obstruction. This review addresses the normal emptying of solids and liquids from the stomach and details the myogenic and neuromuscular control mechanisms, including the specialized function of the pyloric sphincter, that result in normal emptying, based predominantly on animal research. A clear understanding of fundamental mechanisms is necessary to comprehend derangements leading to gastroparesis, and additional research on human gastric muscles is needed. The section on pathophysiology of gastroparesis considers neuromuscular diseases that affect nonsphincteric gastric muscle, disorders of the extrinsic neural control, and pyloric dysfunction that lead to gastroparesis. The potential cellular basis for gastroparesis is attributed to the effects of oxidative stress and inflammation, with increased pro-inflammatory and decreased resident macrophages, as observed in full-thickness biopsies from patients with gastroparesis. Predominant diagnostic tests involving measurements of gastric emptying, the use of a functional luminal imaging probe, and high-resolution antral duodenal manometry in characterizing the abnormal motor functions at the gastroduodenal junction are discussed. Management is based on supporting nutrition; dietary interventions, including the physical reduction in particle size of solid foods; pharmacological agents, including prokinetics and anti-emetics; and interventions such as gastric electrical stimulation and pyloromyotomy. These are discussed briefly, and comment is added on the potential for individualized treatments in the future, based on optimal gastric emptying measurement and objective documentation of the underlying pathophysiology causing the gastroparesis.
Topics: Animals; Enteric Nervous System; Gastric Emptying; Gastroparesis; Humans; Predictive Value of Tests; Pylorus; Treatment Outcome
PubMed: 34717924
DOI: 10.1053/j.gastro.2021.10.028 -
The American Journal of Gastroenterology Aug 2022Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical...
Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
Topics: Adult; Gastric Emptying; Gastroenterology; Gastroparesis; Humans; Pylorus; Risk Factors
PubMed: 35926490
DOI: 10.14309/ajg.0000000000001874 -
Gut Dec 2019Gastroparesis is defined by delayed gastric emptying (GE) and symptoms of nausea, vomiting, bloating, postprandial fullness, early satiety and abdominal pain. Most... (Review)
Review
Gastroparesis is defined by delayed gastric emptying (GE) and symptoms of nausea, vomiting, bloating, postprandial fullness, early satiety and abdominal pain. Most common aetiologies include diabetes, postsurgical and postinfectious, but in many cases it is idiopathic. Clinical presentation and natural history vary by the aetiology. There is significant morbidity and healthcare utilisation associated with gastroparesis. Mechanistic studies from diabetic animal models of delayed GE as well as human full-thickness biopsies have significantly advanced our understanding of this disorder. An innate immune dysregulation and injury to the interstitial cells of Cajal and other components of the enteric nervous system through paracrine and oxidative stress mediators is likely central to the pathogenesis of gastroparesis. Scintigraphy and C breath testing provide the most validated assessment of GE. The stagnant gastroparesis therapeutic landscape is likely to soon see significant changes. Relatively newer treatment strategies include antiemetics (aprepitant), prokinetics (prucalopride, relamorelin) and fundic relaxants (acotiamide, buspirone). Endoscopic pyloromyotomy appears promising over the short term, especially for symptoms of nausea and vomiting. Further controlled trials and identification of the appropriate subgroup with pyloric dysfunction and assessment of long-term outcomes are essential. This review highlights the clinical presentation, diagnosis, mechanisms and treatment advancements for gastroparesis.
Topics: Endoscopy, Gastrointestinal; Gastric Emptying; Gastrointestinal Agents; Gastroparesis; Humans
PubMed: 31563877
DOI: 10.1136/gutjnl-2019-318712 -
The Lancet. Gastroenterology &... Mar 2021Linked to the growing obesity epidemic, demand for bariatric and metabolic surgery has increased, the most common procedures being sleeve gastrectomy and Roux-en-Y... (Review)
Review
Linked to the growing obesity epidemic, demand for bariatric and metabolic surgery has increased, the most common procedures being sleeve gastrectomy and Roux-en-Y gastric bypass. Originally, bariatric procedures were described as purely restrictive, malabsorptive, or combined restrictive-malabsorptive procedures limiting food intake, nutrient absorption, or both. Nowadays, anatomical alterations are known to affect gastrointestinal physiology, which in turn affects the digestion and absorption of nutrients and drugs. Therefore, understanding gastrointestinal physiology is crucial to prevent postoperative nutritional deficiencies and to optimise postoperative drug therapy. Preclinical and clinical research indicates that sleeve gastrectomy accelerates liquid and solid gastric emptying and small intestinal transit, and increases bile acid serum levels, whereas its effects on gastrointestinal acidity, gastric and pancreatic secretions, surface area, and colonic transit remain largely unknown. Roux-en-Y gastric bypass diminishes gastric acid secretion, accelerates liquid gastric emptying, and increases bile acid serum levels, but its effects on intestinal pH, solid gastric emptying, intestinal transit time, gastric enzyme secretions, and surface area remain largely unknown. In this Review, we summarise current knowledge of the effects of these two procedures on gastrointestinal physiology and assess the knowledge gaps.
Topics: Adult; Bile Acids and Salts; Female; Gastrectomy; Gastric Bypass; Gastric Emptying; Gastrointestinal Tract; Gastrointestinal Transit; Humans; Male; Malnutrition; Middle Aged; Postoperative Complications
PubMed: 33581761
DOI: 10.1016/S2468-1253(20)30302-2 -
Nutrition in Clinical Practice :... Feb 2021Enteral feeding intolerance (EFI) is a common feature in critically ill patients worldwide. However, there is no clear, widely agreed-upon definition available, with... (Review)
Review
Enteral feeding intolerance (EFI) is a common feature in critically ill patients worldwide. However, there is no clear, widely agreed-upon definition available, with various studies rarely using the same definition. The term EFI is frequently used to describe vomiting or large gastric residual volumes associated with enteral feeding as a result of gastroparesis/delayed gastric emptying. However, the syndrome of EFI may represent the consequence of various pathophysiological mechanisms, and this heterogeneity may explain varying associations with outcomes. In clinical practice, a pragmatic definition may be useful. A pragmatic definition of EFI is that a clinician has decided to reduce the amount of enteral nutrition specifically because features of gastrointestinal dysfunction appeared during enteral feeding. For research purposes, a more detailed definition of EFI is required to improve knowledge and explore interventions that may improve patient-centered outcomes. The objective of this review is to summarize available evidence on existing definitions, pathophysiological mechanisms, and the clinical relevance of EFI in critically ill patients. Based on current knowledge, we propose a conceptual framework for a definition of EFI for a future consensus process.
Topics: Critical Illness; Enteral Nutrition; Gastric Emptying; Gastrointestinal Diseases; Humans; Infant, Newborn; Stomach
PubMed: 33242218
DOI: 10.1002/ncp.10599 -
Clinical Gastroenterology and... Mar 2022Delayed gastric emptying on objective testing defines gastroparesis, but symptoms overlap with functional dyspepsia and do not correlate well with gastric emptying... (Review)
Review
DESCRIPTION
Delayed gastric emptying on objective testing defines gastroparesis, but symptoms overlap with functional dyspepsia and do not correlate well with gastric emptying delay. This review outlines a strategy for defining, diagnosing, and managing refractory gastroparesis.
METHODS
The Best Practice Advice statements presented here were developed from review of existing literature combined with expert opinion to provide practical advice. Because this was not a systematic review, formal rating of the quality of evidence or strength of recommendations was not performed. BEST PRACTICE ADVICE.
Topics: Dyspepsia; Gastric Emptying; Gastroparesis; Humans
PubMed: 34757197
DOI: 10.1016/j.cgh.2021.10.038 -
European Journal of Anaesthesiology Jan 2022Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent...
Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.
Topics: Anesthesiology; Child; Critical Care; Fasting; Female; Gastric Emptying; Humans; Preoperative Care; Ultrasonography
PubMed: 34857683
DOI: 10.1097/EJA.0000000000001599 -
American Journal of Physiology.... May 2021This study was designed to investigate whether transcutaneous auricular vagal nerve stimulation (taVNS) would be able to improve major pathophysiologies of functional...
This study was designed to investigate whether transcutaneous auricular vagal nerve stimulation (taVNS) would be able to improve major pathophysiologies of functional dyspepsia (FD) in patients with FD. Thirty-six patients with FD (21 F) were studied in two sessions (taVNS and sham-ES). Physiological measurements, including gastric slow waves, gastric accommodation, and autonomic functions, were assessed by the electrogastrogram (EGG), a nutrient drink test and the spectral analysis of heart rate variability derived from the electrocardiogram (ECG), respectively. Thirty-six patients with FD (25 F) were randomized to receive 2-wk taVNS or sham-ES. The dyspeptic symptom scales, anxiety and depression scores, and the same physiological measurements were assessed at the beginning and the end of the 2-wk treatment. In comparison with sham-ES, acute taVNS improved gastric accommodation ( = 0.008), increased the percentage of normal gastric slow waves (%NSW, fasting: = 0.010; fed: = 0.007) and vagal activity (fasting: = 0.056; fed: = 0.026). In comparison with baseline, 2-wk taVNS but not sham-ES reduced symptoms of dyspepsia ( = 0.010), decreased the scores of anxiety ( = 0.002) and depression ( < 0.001), and improved gastric accommodation ( < 0.001) and the %NSW (fasting: < 0.05; fed: < 0.05) by enhancing vagal efferent activity (fasting: = 0.015; fed: = 0.048). Compared with the HC, the patients showed increased anxiety ( < 0.001) and depression ( < 0.001), and decreased gastric accommodation ( < 0.001) and %NSW ( < 0.001) as well as decreased vagal activity (fasting: = 0.047). The noninvasive taVNS has a therapeutic potential for treating nonsevere FD by improving gastric accommodation and gastric pace-making activity via enhancing vagal activity. Treatment of functional dyspepsia is difficult due to various pathophysiological factors. The proposed method of transcutaneous auricular vagal nerve stimulation improves symptoms of both dyspepsia and depression/anxiety, and gastric functions (accommodation and slow waves), possibly mediated via the enhancement of vagal efferent activity. This noninvasive and easy-to-implement neuromodulation method will be well received by patients and healthcare providers.
Topics: Adolescent; Adult; Aged; Autonomic Nervous System; Dyspepsia; Female; Gastric Emptying; Gastrointestinal Motility; Humans; Male; Middle Aged; Stomach; Treatment Outcome; Vagus Nerve; Vagus Nerve Stimulation; Young Adult
PubMed: 33624527
DOI: 10.1152/ajpgi.00426.2020 -
Appetite May 2022This paper is based on a presentation given at the Annual Meeting of the Society for the Study of Ingestive Behavior in July 2021 and provides a personal view on some of... (Review)
Review
This paper is based on a presentation given at the Annual Meeting of the Society for the Study of Ingestive Behavior in July 2021 and provides a personal view on some of the milestones in the discovery of amylin as a constituent of pancreatic islet amyloid deposits, as a pancreatic beta-cell hormone, and on its role in physiology and pathophysiology. Only selected effects of amylin are discussed here because we recently published extensive reviews on the physiology and pathophysiology of amylin. Amylin was discovered as the main constituent of islet amyloid that is predominantly found in pancreatic islets in type 2 diabetics. These deposits, and in particular small oligomer aggregates of amylin seem to contribute to the progressive beta-cell damage seen in type 2 diabetics. Amylin is also a physiologically relevant circulating hormone with diverse metabolic functions, e.g. inhibition of eating, of pancreatic glucagon secretion and of gastric emptying. Knowledge of these types of functions and amylin's mechanisms of action lead to the development of amylin analogues that are now among the most promising anti-obesity targets in clinical testing. With this review, I want to give a short overview of 35 exciting years of amylin research.
Topics: Amyloid; Feeding Behavior; Gastric Emptying; Humans; Islet Amyloid Polypeptide; Obesity
PubMed: 35183619
DOI: 10.1016/j.appet.2022.105965 -
Current Opinion in Critical Care Aug 2019This review provides an update of recently conducted studies and randomized controlled trials evaluating prokinetic drugs. (Review)
Review
PURPOSE OF REVIEW
This review provides an update of recently conducted studies and randomized controlled trials evaluating prokinetic drugs.
RECENT FINDINGS
Prokinetic drugs accelerate gastric emptying and, particularly in patients with gastric dysmotility and enteral feed intolerance, their use increases the delivery of enteral nutrition. However, prokinetic drugs have not been shown to improve patient-centered outcomes in trials but benefit is assumed on the basis of observational studies, which report close associations between gastric dysmotility, enteral feed intolerance and poor outcomes, and improvement in surrogate physiological outcomes when prokinetic drugs are administered.
SUMMARY
It may not be feasible to establish superiority of a prokinetic drug within a randomized controlled trial with a patient-centered event as the primary outcome. The use of metoclopramide and erythromycin as prokinetic drugs is based on observations from trials measuring surrogate physiological outcomes. Randomized controlled trials of alternative drug regimens and novel prokinetic drugs have recently been completed and results outlined.
Topics: Enteral Nutrition; Erythromycin; Gastric Emptying; Gastrointestinal Agents; Humans; Metoclopramide; Observational Studies as Topic; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31247631
DOI: 10.1097/MCC.0000000000000634