Development and validation of a nomogram for predicting clinically relevant delayed gastric emptying in patients undergoing total pancreatectomy.

BACKGROUND: Current research on delayed gastric emptying (DGE) after pancreatic surgery is predominantly focused on pancreaticoduodenectomy (PD), with little exploration into DGE following total pancreatectomy (TP). This study aims to investigate the risk factors for DGE after TP and develop a predictive model. METHODS: This retrospective cohort study included 106 consecutive cases of TP performed between January 2013 and December 2023 at Peking Union Medical College Hospital (PUMCH). After applying the inclusion criteria, 96 cases were selected for analysis. These patients were randomly divided into a training set (n = 67) and a validation set (n = 29) in a 7:3 ratio. LASSO regression and multivariate logistic regression analyses were used to identify factors associated with clinically relevant DGE (grades B/C) and to construct a predictive nomogram. The ROC curve, calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were employed to evaluate the model's prediction accuracy. RESULTS: The predictive model identified end-to-side gastrointestinal anastomosis, intraoperative blood transfusion, and venous reconstruction as risk factors for clinically relevant DGE after TP. The ROC was 0.853 (95%CI 0.681-0.900) in the training set and 0.789 (95%CI 0.727-0.857) in the validation set. The calibration curve, DCA, and CIC confirmed the accuracy and practicality of the nomogram. CONCLUSION: We developed a novel predictive model that accurately identifies potential risk factors associated with clinically relevant DGE in patients undergoing TP.

[An update on gastroparesis in 2024]. / Le point sur la gastroparésie en 2024.

Gastroparesis is a pathology associating upper digestive symptoms, such as nausea and vomiting, with impaired gastric emptying in the absence of mechanical gastric or duodenal obstruction. It has a major impact on patients' quality of life, can lead to undernutrition, and -increases overall mortality. Several schools of thought converge on the hypothesis of a clinico--pathological spectrum of gastric neuro-muscular dysfunction encompassing gastroparesis and functional dyspepsia, in particular the subtype known as "postprandial distress syndrome". Its management includes non--pharmacological interventions, such as hygienic--dietary measures, pharmacological interventions using prokinetic, antiemetic or neuromodulatory treatments, and endoscopic interventions.

La gastroparésie est une pathologie associant des symptômes ­digestifs hauts, tels que des nausées et des vomissements, à un défaut de la vidange gastrique en l'absence d'une obstruction ­mécanique gastrique ou duodénale. Elle a un fort retentissement sur la qualité de vie des patients, peut amener à la dénutrition et augmente globalement la mortalité. Plusieurs courants de pensée convergent vers l'hypothèse d'un spectre clinicopathologique de dysfonction neuromusculaire gastrique englobant la gastroparésie et la dyspepsie fonctionnelle, notamment du sous-­type appelé « syndrome de détresse postprandiale ¼. Sa prise en charge ­comprend des interventions non pharmacologiques, telles que des mesures hygiénodiététiques, des interventions pharmacologiques à l'aide de traitements procinétiques, anti­émétiques ou encore neuromodulateurs, et des interventions ­endoscopiques.

Impact of marmara-yegen cutting gastrojejunostomy on delayed gastric emptying after pancreatoduodenectomy: initial results.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common reasons for morbidity after pancreatoduodenectomy. The technical characteristics of anastomosis that could be affected by surgeon may offer a relevant chance to improve postoperative DGE rates. We investigated the effect of a technical modification of gastrojejunostomy after the classical pancreaticoduodenectomy on DGE. MATERIALS AND METHODS: A total of 161 patients underwent classical pancreaticoduodenectomy (with 20-40 percent antrectomy) due to pancreatic adenocarcinoma at the Department of General Surgery, Marmara University, School of Medicine Hospital, from February 2019 to May 2023, and those who met the inclusion criteria were enrolled. One hundred twenty patients had undergone classical end-to-side gastrojejunostomy (Classical GJ group), and 41 had undergone Marmara-Yegen cutting side-to-side gastrojejunostomy (M-Yc group). DGE was defined according to the International Working Group on Pancreatic Surgery, and postoperative DGE rates of both groups were compared. In addition, multivariate analysis was performed to identify possible independent predictive factors for DGE. RESULTS: The total incidence of DGE was 31% in the Classical GJ group and 17% in the (M-Yc group). Although there was no significant difference between the groups regarding DGE and DGE grades (p = 0.1), DGE was distinctly lower in the M-Yc GJ group. In multi-variant analysis, Clavien-Dindo grade 3a and above postoperative complication was determined as independent predictors for DGE. CONCLUSIONS: We tried to explain the mechanism of DGE in terms of anatomical configuration. The incidence and severity of DGE decreased in patients who underwent M-Yc GJ.

Predicting Response to Neuromodulators or Prokinetics in Patients With Suspected Gastroparesis Using Machine Learning: The "BMI, Infectious Prodrome, Delayed GES, and No Diabetes" Model.

INTRODUCTION: Pharmacologic therapies for symptoms of gastroparesis (GP) have limited efficacy, and it is difficult to predict which patients will respond. In this study, we implemented a machine learning model to predict the response to prokinetics and/or neuromodulators in patients with GP-like symptoms. METHODS: Subjects with suspected GP underwent simultaneous gastric emptying scintigraphy (GES) and wireless motility capsule and were followed for 6 months. Subjects were included if they were started on neuromodulators and/or prokinetics. Subjects were considered responders if their GP Cardinal Symptom Index at 6 months decreased by ≥1 from baseline. A machine learning model was trained using lasso regression, ridge regression, or random forest. Five-fold cross-validation was used to train the models, and the area under the receiver operator characteristic curve (AUC-ROC) was calculated using the test set. RESULTS: Of the 150 patients enrolled, 123 patients received either a prokinetic and/or a neuromodulator. Of the 123, 45 were considered responders and 78 were nonresponders. A ridge regression model with the variables, such as body mass index, infectious prodrome, delayed gastric emptying scintigraphy, no diabetes, had the highest AUC-ROC of 0.72. The model performed well for subjects on prokinetics without neuromodulators (AUC-ROC of 0.83) but poorly for those on neuromodulators without prokinetics. A separate model with gastric emptying time, duodenal motility index, no diabetes, and functional dyspepsia performed better (AUC-ROC of 0.75). DISCUSSION: This machine learning model has an acceptable accuracy in predicting those who will respond to neuromodulators and/or prokinetics. If validated, our model provides valuable data in predicting treatment outcomes in patients with GP-like symptoms.

Disorders of gastric motility.

Gastroparesis is a disorder of delayed gastric emptying with associated symptoms of postprandial fullness, early satiety, nausea, vomiting, bloating, and abdominal pain. Functional dyspepsia is an upper gastrointestinal disorder of gut-brain interaction that presents with similar symptoms but is defined according to symptom patterns rather than gastric motor dysfunction. Although delayed gastric emptying is a defining feature of gastroparesis, other aspects of gastric neuromuscular dysfunction, such as gastric accommodation and visceral hypersensitivity might contribute to symptoms. Similarly, although functional dyspepsia is not defined by impaired gastric emptying, disordered gastric motility might underlie pathogenesis in some patients with functional dyspepsia. In the last decade, it has been increasingly recognised that these two disorders might represent varying presentations along a common continuum of neuromuscular dysfunction, although with differentiating features with respect to outcomes, diagnosis, and treatments. In this Review, an overview of gastroparesis and functional dyspepsia from the perspective of gastric motility is provided, discussing what is distinct and what is shared between these disorders.

Endoscopic pyloromyotomy for treatment of gastroparesis: A new standard or still an experimental approach?

Gastroparesis (GP) can be a severe and debilitating disease. Its pathophysiology is complex and not completely understood. Two principal mechanisms are responsible for the development of symptoms - gastric hypomotility and pylorospasm. Pylorus targeted therapies aim to decrease presumably elevated pyloric tone - pylorospasm. There is a growing body of evidence about their role in the treatment algorithm of GP. G-POEM (endoscopic pyloromyotomy) is an extensively studied pylorus targeted therapy. Its efficacy ranges between 56 and 80% and the number of recurrences among those with treatment effect seems low. G-POEM is a safe procedure with very low frequency of severe adverse events. At present, G-POEM should not be considered as an experimental approach and may be offered to all patients with refractory and severe GP. Nevertheless, G-POEM is not a first line treatment. Conservative measures such as diet modification and pharmacotherapy should always be tried before G-POEM is considered. Further research must focus on better patient selection as at present there are no standardized criteria. Functional imaging such as impedance planimetry (EndoFlip) may hold promise in this regard.

Addition of pyloroplasty may improve glycemic control and refractory early satiety in gastroparesis at rates similar to gastric neurostimulation alone: a retrospective analysis.

OBJECTIVES: Gastroparesis that is refractory to standard dietary and medical management may benefit from surgical treatment with gastric electrical neurostimulation, which has shown promise in reducing symptoms of the disease. Pyloroplasty may serve an adjunctive role to a gastric stimulator, but the precise benefit remains unclear. The present study compares reported rates of symptom improvement following gastric neurostimulator implantation with and without pyloroplasty. MATERIALS AND METHODS: A single center retrospective analysis of consecutive patients who received operative management for symptom refractory gastroparesis from 1 January 2020 to 31 December 2021 was performed. Subjects were assigned to cohorts based on treatment with gastric electrical stimulation alone (GES-only) or combined with pyloroplasty (GES + PP). A survey-based assessment was administered post-operatively that evaluated cardinal symptoms of gastroparesis (nausea, vomiting, early satiety) before and after treatment. RESULTS: In total, 42 patients (15 GES-only, 27 GES + PP) were included in the study. Both groups reported a high degree of improvement in global symptom control following surgery (93% vs 81%) with no differences between treatment cohorts (p = 0.09). Early satiety demonstrated better improvement in patients who received gastric stimulation alone (p = 0.012). Subgroup analysis of diabetic gastroparesis patients showed a 2.2% decrease in hemoglobin A1c levels in the GES + PP group (p-0.034). CONCLUSIONS: Symptom reduction in refractory gastroparesis appears to improve after placement of a gastric neurostimulator with or without the addition of a pyloroplasty procedure.

Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are effective in diabetes and obesity, reducing hyperglycemia by increasing insulin release and delaying gastric emptying. However, they can cause gastroparesis, raising concerns about aspiration during procedures. Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration. AIM: To evaluate the effect of GLP-1 RAs on gastric residual contents during endoscopic procedures. METHODS: A retrospective chart review at BronxCare Health System, New York, from January 2019 to October 2023, assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures. Two groups were compared based on dietary status before the procedure. Data included demographics, symptoms of gastroparesis, opiate use, hemoglobin A1c, GLP-1 agonist indication, endoscopic details, and aspiration occurrence. IBM SPSS was used for analysis, calculating means, standard deviations, and applying Pearson's chi-square and t-tests for associations, with P < 0.05 as being significant. RESULTS: During the study, 306 patients were included, with 41.2% on a clear liquid/low residue diet and 58.8% on a regular diet before endoscopy. Most patients (63.1%) were male, with a mean age of 60 ± 12 years. The majority (85.6%) were on GLP-1 RAs for diabetes, and 10.1% reported digestive symptoms before endoscopy. Among those on a clear liquid diet, 1.5% had residual food at endoscopy compared to 10% on a regular diet, which was statistically significant (P = 0.03). Out of 31 patients with digestive symptoms, 13% had residual food, all from the regular diet group (P = 0.130). No complications were reported during or after the procedures. CONCLUSION: The study reflects a significant rise in GLP-1 RA use for diabetes and obesity. A 24-hour liquid diet seems safe for endoscopic procedures without aspiration. Patients with upper gastrointestinal symptoms might have a higher residual food risk, though not statistically significant. Further research is needed to assess risks based on diabetes duration, gastroparesis, and GLP-1 RA dosing, aiming to minimize interruptions in therapy during procedures.

Intra-operative pyloric BOTOX injection versus pyloric surgery for prevention of delayed gastric emptying after esophagectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after esophagectomy. BOTOX injections and pyloric surgeries (PS), including pyloroplasty (PP) and pyloromyotomy (PM), are performed intraoperatively as prophylaxis against DGE. This study compares the effects of pyloric BOTOX injection and PS for preventing DGE post-esophagectomy. METHODS: We retrospectively reviewed Moffitt's IRB-approved database of 1364 esophagectomies, identifying 475 patients receiving BOTOX or PS during esophageal resection. PS was further divided into PP and PM. Demographics, clinical characteristics, and postoperative outcomes were compared using Chi-Square, Fisher's exact test, Wilcoxon rank-sum, and ANOVA. Propensity-score matching was performed between BOTOX and PP cohorts. RESULTS: 238 patients received BOTOX, 108 received PP, and 129 received PM. Most BOTOX patients underwent fully minimally invasive robotic Ivor-Lewis esophagectomy (81.1% vs 1.7%) while most PS patients underwent hybrid open/Robotic Ivor-Lewis esophagectomy (95.7% vs 13.0%). Anastomotic leak (p = 0.57) and pneumonia (p = 0.75) were comparable between groups. However, PS experienced lower DGE rates (15.9% vs 9.3%; p = 0.04) while BOTOX patients had less postoperative weight loss (9.7 vs 11.45 kg; p = 0.02). After separating PP from PM, leak (p = 0.72) and pneumonia (p = 0.07) rates remained similar. However, PP patients had the lowest DGE incidence (1.9% vs 15.7% vs 15.9%; p = < 0.001) and the highest bile reflux rates (2.8% vs 0% vs 0.4%; p = 0.04). Between matched cohorts of 91 patients, PP had lower DGE rates (18.7% vs 1.1%; p = < 0.001) and less weight loss (9.8 vs 11.4 kg; p = < 0.001). Other complications were comparable (all p > 0.05). BOTOX was consistently associated with shorter LOS compared to PS (all p = < 0.001). CONCLUSION: PP demonstrates lower rates of DGE in unmatched and matched analyses. Compared to BOTOX, PS is linked to reduced DGE rates. While BOTOX is associated with more favorable LOS, this may be attributable to difference in operative approach. PP improves DGE rates after esophagectomy without improving other postoperative complications.

Outcome of gastric electrical stimulator with and without pyloromyotomy for refractory gastroparesis.

BACKGROUND: Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy. METHODS: Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal. RESULTS: During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03-6.94, p = 0.044). CONCLUSION: Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy.

Point-of-Care Ultrasound for Gastric Volume Measurement in a Pediatric Patient-Look Beyond the Antrum: A Case Report.

Gastric ultrasound estimates stomach contents in perioperative patients. A 10-year-old boy with abdominal rhabdomyosarcoma, who received abdominal radiation, developed gastroparesis and was scheduled for endoscopic gastrointestinal pyloric dilation. Point-of-care gastric ultrasound revealed gastric antral cross-sectional area of 6.5 cm2 (estimated gastric content ~30 mL). However, dynamic right-to-left ultrasound revealed more hypoechoic material in the fundus of the stomach. On induction ~125 mL of stomach contents was suctioned. Antral measurements may not accurately predict the stomach contents in the setting of a stiff/fixed antrum. Scanning from antrum to fundus determined contents more accurately, especially with a prior history of abdominal radiation.

The role of diet in diabetes gastroparesis treatment: a systematic review and meta-analysis.

Background: Diabetic gastroparesis is a common complication in patient with diabetes. Dietary intervention has been widely used in the treatment of diabetic gastroparesis. The aim of this study is to evaluate the role of diet in the treatment of diabetic gastroparesis. Methods: This systematic review was conducted a comprehensive search of randomized controlled trials using dietary interventions for the treatment of diabetic gastroparesis up to 9 November 2023. The primary outcomes were gastric emptying time and clinical effect, while fasting blood glucose, 2-hour postprandial blood glucose and glycosylated hemoglobin were secondary outcomes. Data analysis was performed using RevMan 5.4 software, and publication bias test was performed using Stata 15.1 software. Results: A total of 15 randomized controlled trials involving 1106 participants were included in this review. The results showed that patients with diabetic gastroparesis benefit from dietary interventions (whether personalized dietary care alone or personalized dietary care+routine dietary care). Compared with routine dietary care, personalized dietary care and personalized dietary care+routine dietary care can shorten the gastric emptying time, improve clinical efficacy, and reduce the level of fasting blood glucose, 2-hour postprandial blood glucose and glycosylated hemoglobin. Conclusions: Limited evidence suggests that dietary intervention can promote gastric emptying and stabilize blood glucose control in patients with diabetic gastroparesis. Dietary intervention has unique potential in the treatment of diabetic gastroparesis, and more high-quality randomized controlled trials are needed to further validate our research results. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023481621.

Enteric neuropathy in diabetes: Implications for gastrointestinal function.

Diabetes, commonly known for its metabolic effects, also critically affects the enteric nervous system (ENS), which is essential in regulating gastrointestinal (GI) motility, secretion, and absorption. The development of diabetes-induced enteric neuropathy can lead to various GI dysfunctions, such as gastroparesis and irregular bowel habits, primarily due to disruptions in the function of neuronal and glial cells within the ENS, as well as oxidative stress and inflammation. This editorial explores the pathophysiological mechanisms underlying the development of enteric neuropathy in diabetic patients. Additionally, it discusses the latest advances in diagnostic approaches, emphasizing the need for early detection and intervention to mitigate GI complications in diabetic individuals. The editorial also reviews current and emerging therapeutic strategies, focusing on pharmacological treatments, dietary management, and potential neuromodulatory interventions. Ultimately, this editorial highlights the necessity of a multidisciplinary approach in managing enteric neuropathy in diabetes, aiming to enhance patient quality of life and address a frequently overlooked complication of this widespread disease.

[Management of gastroparesis care in Germany - a survey by the working group of guiding gastroenterologic clinicians (Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte, ALGK)]. / Versorgungsrealität der Gastroparese in Deutschland ­ eine Umfrage der Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte (ALGK).

INTRODUCTION: The treatment of gastroparesis can be difficult in everyday clinical practice. The aim of this anonymous survey of members of the Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte e.V. (ALGK) was to investigate the management of gastroparesis care in Germany. MATERIAL AND METHODS: The ALGK conducted a member survey using a standardized anonymous questionnaire including 11 questions from 14.04.2023 to 29.04.2023. The questions covered diagnostic and therapeutic procedures as well as various aspects of the management of gastroparesis. RESULTS: The response rate was 21.4% (62 members). Only 6.56% of all respondents assessed the prevalence of gastroparesis correctly as estimated by current epidemiological publications. 68.85 % of all respondents used gastric emptying scintigraphy for diagnosis. 51.61% regarded an individualized therapy as the most important treatment goal, taking into account etiology and impact of symptoms, compared to symptomatic treatment of leading clinical symptom in 43,55 %. First choice treatment was medical treatment in 41.94%, dietary recommendations in 27.42% and endoscopic interventions in 24.2%. 100% of respondents used prokinetics, 40.32% used antiemetics while only 4.84% used analgesics. Insufficient availability of medical treatment options represents a need of action for 85.48%, compared to lacking official approval of available drugs for this indication for 48,39% of all respondents. Treatment options with little evidence were used quite frequently (e.g. use of herbal therapies in 43.55%). DISCUSSION: Overall, the frequency of gastroparesis was underestimated in the current survey. Endoscopic options are quite often used as first-line treatment. Although symptom-guided treatment is important for the majority of respondents, prokinetics are predominantly used.

Gastroparesis treatment options metoclopramide and prucalopride: analysis of the FDA Adverse Event Reporting System (FAERS) database.

BACKGROUND: We aimed to examine the common adverse drug reactions (ADRs) of metoclopramide, FDA-approved for treating many gastrointestinal conditions including gastroparesis, and prucalopride, FDA-approved for treating chronic idiopathic constipation but used off-label for other gastrointestinal conditions including gastroparesis. RESEARCH DESIGN AND METHODS: The FDA Adverse Event Reporting System (FAERS) was analyzed from January 2013 to December 2023. ADR reports regarding use of only metoclopramide or prucalopride were analyzed following exclusion of reports indicating use for treatment of non-gastrointestinal conditions. RESULTS: Analysis of 1,085 reports on metoclopramide revealed tardive dyskinesia (n = 393, 36.2%) and dystonia (n = 170, 15.7%) among the most reported ADRs in addition to QTc prolongation (n = 16, 1.5%) with progression to Torsade de pointes (n = 5, 0.5%) and triggering of pheochromocytoma crisis (n = 24, 2.2%). Analysis of 865 reports on prucalopride revealed headache (n = 120, 13.9%), diarrhea (n = 116, 13.4%), and abdominal pain (n = 100, 11.6%) as the most common ADRs with 22 reports (2.5%) of dystonia with the use of prucalopride. CONCLUSIONS: This FAERS database analysis shows post-marketing reports of ADRs from metoclopramide most frequently include tardive dyskinesia, dystonia, and tremor in addition to potentially fatal arrhythmias such as Torsade de pointes. Consumers of prucalopride may also be at risk of dystonia and other ADRs.

A novel pilot study to evaluate the efficacy and safety of a wireless patch system in patients with chronic nausea and vomiting.

BACKGROUND: Gastric sensorimotor disorders (functional dyspepsia [FD] and gastroparesis [GP]) are prevalent and burdensome. Prolonged ambulatory recording using a wireless patch may provide novel information in these patients. METHODS: Consecutive adult patients (age ≥ 18 years) referred for gastric emptying scintigraphy (GES) were eligible for study inclusion. Patients were excluded if they had prior foregut surgery; were taking opioids or other medications known to affect gastric emptying; had a HgbA1C > 10; or were recently hospitalized. Three wireless motility patches were applied to the skin prior to GES. Patients wore the patches for 6 days while recording meals, symptoms, and bowel movements using an iPhone app. KEY RESULTS: Twenty-three consecutive adults (87% women; mean age = 43.9 years; mean BMI = 26.7 kg/m2) were enrolled. A gastric histogram revealed three levels of gastric myoelectric activity: weak, moderate, and strong. Patients with delayed gastric emptying at 4 h had weak gastric myoelectrical activity. Patients with nausea and vomiting had strong intestinal activity. Those with FD had weak gastric and intestinal myoelectric activity, and a weak meal response in the stomach, intestine, and colon compared to those with nausea alone or vomiting alone. CONCLUSIONS AND INFERENCES: Patients with FD, and those with delayed gastric emptying, had unique gastrointestinal myoelectrical activity patterns. Reduced postprandial pan-intestinal myoelectric activity may explain the symptoms of FD in some patients. Recording gastrointestinal activity over a prolonged period in the outpatient setting has the potential to identify unique pathophysiologic patterns and meal-related activity that distinguishes patients with distinct gastric sensorimotor disease states.

Effects of ondansetron on symptoms during a gastric emptying study and enteral lipid challenge and on daily symptoms in diabetic gastroenteropathy.

BACKGROUND: This study compared the effects of ondansetron and placebo in patients with diabetes mellitus and symptoms of dyspepsia (diabetic gastroenteropathy [DGE]). METHODS: We performed a randomized, double-blinded, placebo-controlled study of ondansetron tablets (8 mg) three times daily for 4 weeks in DGE patients. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index daily diaries. Gastric emptying (GE) of solids (scintigraphy) and duodenal lipid infusions (300 kcal over 2 h) were each assessed twice, with placebo and ondansetron. Drug effects on GE, symptoms during the GE study and during lipid infusion, and daily symptoms were analyzed. KEY RESULTS: Of 41 patients, 37 completed both GE studies and one completed 1; 31 completed both lipid infusions and four only placebo; and all 35 randomized patients completed 4 weeks of treatment. Compared to placebo, ondansetron reduced the severity of fullness (p = 0.02) and belching (p = 0.049) during lipid infusion but did not affect GE T1/2. Both ondansetron and placebo improved daily symptoms versus the baseline period (p < 0.05), but the differences were not significant. In the analysis of covariance of daily symptoms during the treatment period, the interaction term between treatment and the acute effect of ondansetron on symptoms during lipid challenge was significant (p = .024). CONCLUSIONS & INFERENCES: Ondansetron significantly reduced fullness during enteral lipid infusion in patients with DGE. Overall, ondansetron did not improve daily symptoms versus placebo. But patients in whom ondansetron improved symptoms during enteral lipid challenge were perhaps more likely to experience symptom relief during daily treatment.

Treatment and Management of Gastrointestinal Disorders.

This article reviews the evaluation and management of several gastrointestinal disorders that are commonly encountered by gastroenterologists and primary care physicians. With a focus on newer therapies, we discuss the management of chronic constipation, irritable bowel syndrome, Clostridioides difficile infection, gastroparesis, steatotic liver disease, and diverticulitis.

Neumatosis quística intestinal, un reto diagnóstico: reporte de caso / Cystic intestinal pneumatosis, a diagnostic challenge: case report

Introducción. La neumatosis quística intestinal se describe como la presencia de gas dentro de la pared intestinal. Es una entidad poco frecuente, con una incidencia del 0,03 % en la población global. Aparece con predilección en el género masculino después de los 45 años yse localiza principalmente en el intestino delgado (42 %) y el colon. Se puede asociar a varias condiciones que en ocasiones requieren manejo quirúrgico. Caso clínico. Se presenta el caso de un hombre 75 años, con antecedente de hipertensión arterial, quien consultó por un cuadro de 15 días de evolución consistente en distensión abdominal, dolor y estreñimiento. En urgencias se solicitó una radiografía de tórax que mostró neumoperitoneo y varios niveles hidroaéreos, por lo que el cirujano de turno consideró una posible ruptura de víscera hueca. Resultados. Fue llevado a laparotomía exploratoria, donde se identificó neumatosis quística intestinal y estómago muy aumentado de tamaño, compatible con gastroparesia. Como resultado del tratamiento brindado, el paciente tuvo un desenlace satisfactorio logrando alta médica, apoyado con cuidados básicos de enfermería. Conclusiones. Si bien los casos de neumatosis quística intestinal son de presentación inusual, se puede encontrar en pacientes con hallazgos imagenológicos de neumoperitoneo. Por eso, se debe realizar un análisis concienzudo de cada paciente e individualizar el caso para el correcto diagnóstico.

Introduction. Cystic pneumatosis intestinalis is described as the presence of gas within the intestinal wall. It is a rare entity, with an incidence of 0.03% in the global population. It appears with a predilection in the male gender after 45 years of age and is located mainly in the small intestine (42%) and the colon. It can be associated with several conditions that sometimes require surgical management. Clinical case. The case of a 75-year-old man with a history of high blood pressure is presented, who consulted for a 15-day history consisting of abdominal distention, pain and constipation. In the emergency room, a chest x-ray was requested, which showed pneumoperitoneum and several air-fluid levels. The surgeon on call considered a possible rupture of the hollow viscus. Results. The patient was taken to exploratory laparotomy, where intestinal cystic pneumatosis and a greatly enlarged stomach were identified, compatible with gastroparesis. As a result of the treatment provided, the patient had a satisfactory outcome, achieving medical discharge, supported with basic nursing care. Conclusions. Although cases of intestinal cystic pneumatosis have an unusual presentation, it can be found in patients with imaging findings of pneumoperitoneum. Therefore, a thorough analysis of each patient must be carried out and the case individualized for the correct diagnosis.