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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 -
Neurogastroenterology and Motility Jan 2021Since publication of Chicago Classification version 3.0 in 2015, the clinical and research applications of high-resolution manometry (HRM) have expanded. In order to... (Review)
Review
Since publication of Chicago Classification version 3.0 in 2015, the clinical and research applications of high-resolution manometry (HRM) have expanded. In order to update the Chicago Classification, an International HRM Working Group consisting of 52 diverse experts worked for two years and utilized formally validated methodologies. Compared with the prior iteration, there are four key modifications in Chicago Classification version 4.0 (CCv4.0). First, further manometric and non-manometric evaluation is required to arrive at a conclusive, actionable diagnosis of esophagogastric junction (EGJ) outflow obstruction (EGJOO). Second, EGJOO, distal esophageal spasm, and hypercontractile esophagus are three manometric patterns that must be accompanied by obstructive esophageal symptoms of dysphagia and/or non-cardiac chest pain to be considered clinically relevant. Third, the standardized manometric protocol should ideally include supine and upright positions as well as additional manometric maneuvers such as the multiple rapid swallows and rapid drink challenge. Solid test swallows, postprandial testing, and pharmacologic provocation can also be considered for particular conditions. Finally, the definition of ineffective esophageal motility is more stringent and now encompasses fragmented peristalsis. Hence, CCv4.0 no longer distinguishes between major versus minor motility disorders but simply separates disorders of EGJ outflow from disorders of peristalsis.
Topics: Esophageal Motility Disorders; Esophagogastric Junction; Humans; Manometry; Peristalsis
PubMed: 33340190
DOI: 10.1111/nmo.14053 -
Medicine Aug 2018The contemporary demographics and prevalence of Meckel's diverticulum, clinical presentation and management is not well described. Thus, this article aims to review the... (Review)
Review
BACKGROUND
The contemporary demographics and prevalence of Meckel's diverticulum, clinical presentation and management is not well described. Thus, this article aims to review the recent literature concerning Meckel's diverticulum.
METHODS
A systematic PubMed/Medline database search using the terms "Meckel" and "Meckel's" combined with "diverticulum." English language articles published from January 1, 2000 to July 31, 2017 were considered. Studies reporting on the epidemiology of Meckel's diverticulum were included.
RESULTS
Of 857 articles meeting the initial search criteria, 92 articles were selected. Only 4 studies were prospective. The prevalence is reported between 0.3% and 2.9% in the general population. Meckels' diverticulum is located 7 to 200 cm proximal to the ileocecal valve (mean 52.4 cm), it is 0.4 to 11.0 cm long (mean 3.05 cm), 0.3 to 7.0 cm in diameter (mean 1.58 cm), and presents with symptoms in 4% to 9% of patients. The male-to-female (M:F 1.5-4:1) gender distribution is reported up to 4 times more frequent in men. Symptomatic patients are usually young. Of the pediatric symptomatic patients, 46.7% have obstruction, 25.3% have hemorrhage, and 19.5% have inflammation as presenting symptom. Corresponding values for adults are 35.6%, 27.3%, and 29.4%. Ectopic gastric tissue is present in 24.2% to 71.0% of symptomatic Meckel's diverticulum, is associated with hemorrhage and is the most common form of ectopic tissue, followed by ectopic pancreatic tissue present in 0% to 12.0%.
CONCLUSION
The epidemiological patterns and clinical presentation appears stable in the 21st century. A symptomatic Meckel's diverticulum is managed by resection. The issue of prophylactic in incidental Meckel's diverticulum resection remains controversial.
Topics: Adolescent; Adult; Aged; Child; Child, Preschool; Choristoma; Disease Management; Female; Humans; Ileocecal Valve; Male; Meckel Diverticulum; Middle Aged; Pancreas; Prevalence; Sex Distribution; Stomach; Young Adult
PubMed: 30170459
DOI: 10.1097/MD.0000000000012154 -
Gut and Liver Sep 2022Gastric outlet obstruction (GOO) is a relatively common condition in which mechanical obstruction of the pylorus, distal stomach, or duodenum causes severe symptoms such... (Review)
Review
Gastric outlet obstruction (GOO) is a relatively common condition in which mechanical obstruction of the pylorus, distal stomach, or duodenum causes severe symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its etiology includes both benign and malignant disorders. Currently, GOO has many treatment options, including initial conservative therapeutic protocols and more invasive procedures, such as surgical gastroenterostomy, stent placement and, the most recently implemented procedure, endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Each procedure has its merits, with surgery often prevailing in patients with longer life expectancy and stents being used most often in patients with malignant gastric outlet stenosis. The newly developed EUS-GE combines the immediate effect of stents and the long-term efficacy of gastroenterostomy. However, this novel method is a technically demanding process that requires expert experience and special facilities. Thus, the true clinical effectiveness, as well as the duration of the effects of EUS-GE, still need to be determined.
Topics: Endosonography; Gastric Outlet Obstruction; Gastroenterostomy; Humans; Pylorus; Stents
PubMed: 35314520
DOI: 10.5009/gnl210327 -
Archives of Pathology & Laboratory... Jun 2017Angiolipoma is a benign tumor composed of adipose tissue and proliferating blood vessels that is commonly found in the subcutaneous tissue of the trunk and extremities.... (Review)
Review
Angiolipoma is a benign tumor composed of adipose tissue and proliferating blood vessels that is commonly found in the subcutaneous tissue of the trunk and extremities. Gastric angiolipoma is a rare entity, and to the best of our knowledge, only 4 cases have been reported in the English-language literature thus far. These tumors may present as gastrointestinal bleeding and anemia or with obstructive symptoms. Accurate preoperative diagnosis is challenging because of nonspecific clinical symptoms and lack of specific findings on imaging studies. The correct diagnosis is usually made by histopathologic examination. The clinical significance lies in being aware of this rare entity in the stomach and distinguishing it from other benign and malignant gastric neoplasms that may be in the differential diagnosis. We herein discuss the clinical presentation, radiologic and histopathologic features, ancillary studies, differential diagnosis, and treatment and prognosis of this rare entity.
Topics: Adipose Tissue; Angiolipoma; Diagnosis, Differential; Humans; Stomach; Stomach Neoplasms
PubMed: 28557598
DOI: 10.5858/arpa.2016-0239-RS -
World Journal of Gastroenterology Apr 2020Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor... (Review)
Review
Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.
Topics: Endoscopy, Gastrointestinal; Endosonography; Gastric Outlet Obstruction; Gastroenterostomy; Humans; Jejunum; Length of Stay; Neoplasm Staging; Palliative Care; Pancreatic Neoplasms; Quality of Life; Reoperation; Self Expandable Metallic Stents; Stomach; Stomach Neoplasms; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Interventional
PubMed: 32390697
DOI: 10.3748/wjg.v26.i16.1847 -
International Journal of Surgery Case... Apr 2022Heterotopic pancreas (HP) is an uncommon and often incidental finding in clinical practice. It is the presence of pancreatic tissue distinct from the normal pancreas and...
INTRODUCTION
Heterotopic pancreas (HP) is an uncommon and often incidental finding in clinical practice. It is the presence of pancreatic tissue distinct from the normal pancreas and with its own ductal and vascular supply. Distal stomach is the most common location of heterotopic pancreas followed by duodenum and jejunum. Most patients with heterotopic pancreas are asymptomatic. Gastric outlet obstruction is a rare presentation of heterotopic pancreas that can follow chronic inflammation and fibrosis of the pylorus from pancreatic secretion, pancreatitis, or malignant transformation. Heterotopic pancreas can be confused for gastric carcinomas on CECT and endoscopy. The aim of this paper is to present a rare case of gastric outlet obstruction due to heterotopic pancreas, mistaken for gastric cancer on endoscopy and CT scan, and its management.
PRESENTATION OF THE CASE
A 45 years old male from Adama, Ethiopia presented with vomiting of 8 months, which worsened since the last one month. He has no history of smoking and diabetes. He occasionally drinks alcohol. Physical examination was normal. CECT scan and endoscopy suggested distal gastric cancer. Radical subtotal gastrectomy done as gastric cancer couldn't be ruled out with excellent outcome. Histopathology revealed obstructing prepyloric chronic fibrosis and heterotopic pancreas.
DISCUSSION
Heterotopic pancreas is a rare pathological entity, clinical diagnosis is difficult preoperatively and frequently an incidental finding at laparotomy.
CONCLUSION
Though rare, heterotopic pancreas can present with gastric outlet obstruction and cause diagnostic confusion with gastric cancer. Definitive diagnosis is by histology that can also guide limited resection intraoperatively.
PubMed: 35367947
DOI: 10.1016/j.ijscr.2022.106974 -
Digestion 2024Esophageal motility disorders (EMDs) are caused by the impaired relaxation of the upper/lower esophageal sphincter and/or defective esophageal peristaltic contractions,... (Review)
Review
BACKGROUND
Esophageal motility disorders (EMDs) are caused by the impaired relaxation of the upper/lower esophageal sphincter and/or defective esophageal peristaltic contractions, resulting in dysphagia and noncardiac chest pain. High-resolution manometry (HRM) is essential for the diagnosis of primary EMD; however, the recognition of EMD and HRM by general practitioners in Japan is limited. This review summarizes the diagnosis of and treatment strategies for EMD.
SUMMARY
HRM is a specific test for the diagnosis of EMD, whereas endoscopy and barium swallow as screening tests provide characteristic findings (i.e., esophageal rosette and bird's beak sign) in some cases. It is important to note that manometric diagnoses apart from achalasia are often clinically irrelevant; therefore, the recently updated guidelines suggest additional manometric maneuvers, such as the rapid drink challenge, and further testing, including functional lumen imaging, for a more accurate diagnosis before invasive treatment. Endoscopic/surgical myotomy, pneumatic dilation, and botulinum toxin injections need to be considered for patients with achalasia and clinically relevant esophagogastric junction outflow obstruction.
KEY MESSAGE
Since the detailed pathophysiology of EMD remains unclear, their diagnosis needs to be cautiously established prior to the initiation of invasive treatment.
Topics: Humans; Esophageal Achalasia; Esophageal Motility Disorders; Deglutition Disorders; Esophageal Sphincter, Lower; Manometry; Endoscopy, Gastrointestinal; Esophagogastric Junction
PubMed: 37634495
DOI: 10.1159/000533347