Disorders of Gut-brain Interaction on the US-Mexico Border: A Survey Using Rome IV Criteria.

BACKGROUND: Disorders of gut-brain interaction (DGBI) cause a substantial health burden. Herein we studied the prevalence and characteristics of DGBI and symptoms of bloating/distension in El Paso, Texas on the US-Mexico border, providing a unique opportunity to study the effects of acculturation. METHODS: Subjects from community centers completed the Rome IV questionnaire for DGBI, short acculturation scale for Hispanics questionnaire, and bloating/distention Pictograms. Data were presented as prevalence (95% CI) and compared using χ 2 . RESULTS: Of 216 participants, 197 (127 Hispanics, 90 with English acculturation) were included and 177 completed the Pictograms. Fifty-one [25.9% (20 to 32.6)] subjects fulfilled the criteria for at least one DGBI. Globus and functional dyspepsia were the most common upper DGBI, each in [3.0% (1.1 to 6.5)]. Unspecified functional bowel disorders [8.6% (5.1 to 13.5)], followed by functional abdominal bloating/distention [8.1% (4.7 to 12.9], and irritable bowel syndrome [6.1% (3.2 to 10.4] were the most common functional bowel disorder. Ninety-one (51.4%) reported bloating and/or distension with Pictograms; more frequently in those with DGBI (80.9% vs 40.8%, P < 0.001). Bloating and/or distension were reported by Pictograms in 30% of those not reporting it in the Rome IV Questionnaire. There were no differences based on acculturation or in Hispanics versus non-Hispanics. CONCLUSIONS: On the US-Mexico border, we found a lower prevalence of DGBI than in the US or Mexico. Functional abdominal bloating/distention was more prevalent on the US-Mexico border than in either country. Bloating/distension was more commonly reported with Pictograms than with verbal descriptors. There were no differences between Hispanics and non-Hispanics, suggesting shared environmental/acquired including dietary factors as the underlying mechanisms.

Plasma endocannabinoids and cannabimimetic fatty acid derivatives are altered in cyclic vomiting syndrome: The effects of sham feeding.

Cyclic vomiting syndrome (CVS) is an underdiagnosed disorder of the gut-brain interaction. Our understanding of the pathophysiology of CVS is evolving. Here, we tested the hypotheses that: (1) the levels of endocannabinoids and related lipids are altered in CVS, and (2) cephalic-vagal stimulation drive changes in endolipid levels. Ten adult patients with CVS and eight healthy controls were included. Indirect measurements of parasympathetic (RFa) functions were performed with spectral analysis of heart rate variability and respiratory activity. Plasma levels of endocannabinoids and related lipids were measured at baseline and during a sham feeding. Values are reported as mean ± standard error of the mean and compared using t-test or ANOVA. CVS patients had a lower parasympathetic tone and response to the Valsalva maneuver and deep breathing than the controls. The baseline 2-Arachidonoylglycerol (2-AG) had a significantly higher concentration in CVS (5.9e-008 ± 3.7e-008 mol/L) than control (3.7e-008 ± 1.3e-008 mol/; p < 0.05). Sham feeding did not change the concentration of 2-AG. 2-oleoylglycerol (2-OG) was significantly higher in CVS than control and did not change with sham feeding. Levels of N-acylethanolamines, including anandamide (AEA), were not different in CVS vs control. After sham feeding, AEA showed a trend toward increasing (p = 0.08) in CVS, but not in control. With sham feeding, palmitoyl ethanolamine significantly increased in both CVS and control groups; oleoyl ethanolamine in CVS only, and stearoyl ethanolamine in the control group. Levels of endocannabinoids and related lipids are altered in CVS patients. Sham feeding affects endogenous signaling lipids in a disease and time-dependent manner.

Inhibiting Fatty Acid Amide Hydrolase Ameliorates Enteropathy in Diabetic Mice: A Cannabinoid 1 Receptor Mediated Mechanism.

Gastrointestinal (GI) dysmotility in diabetics exhibits fecal incontinence or constipation which affects patients' quality of life. In this study, we aimed to understand the pattern of GI transit in type 1 diabetic (T1D) mice and whether inhibiting endocannabinoid degradation would exhibit therapeutic effect. Whole gut-transit time and fecal-pellet output were measured at 16 week post-diabetes. T1D mice treated with fatty acid amide hydrolase (FAAH) inhibitor URB597 showed reduced fecal output as well as improved gut transit time. Cannabinoid 1 receptor antagonist, AM251 blocked the effects of URB597, which may demonstrate that FAAH inhibitor is a potential remedial strategy for GI dysmotility.

Gastrointestinal symptoms and the severity of COVID-19: Disorders of gut-brain interaction are an outcome.

BACKGROUND: Many of the studies on COVID-19 severity and its associated symptoms focus on hospitalized patients. The aim of this study was to investigate the relationship between acute GI symptoms and COVID-19 severity in a clustering-based approach and to determine the risks and epidemiological features of post-COVID-19 Disorders of Gut-Brain Interaction (DGBI) by including both hospitalized and ambulatory patients. METHODS: The study utilized a two-phase Internet-based survey on: (1) COVID-19 patients' demographics, comorbidities, symptoms, complications, and hospitalizations and (2) post-COVID-19 DGBI diagnosed according to Rome IV criteria in association with anxiety (GAD-7) and depression (PHQ-9). Statistical analyses included univariate and multivariate tests. RESULTS: Five distinct clusters of symptomatic subjects were identified based on the presence of GI symptoms, loss of smell, and chest pain, among 1114 participants who tested positive for SARS-CoV-2. GI symptoms were found to be independent risk factors for severe COVID-19; however, they did not always coincide with other severity-related factors such as age >65 years, diabetes mellitus, and Vitamin D deficiency. Of the 164 subjects with a positive test who participated in Phase-2, 108 (66%) fulfilled the criteria for at least one DGBI. The majority (n = 81; 75%) were new-onset DGBI post-COVID-19. Overall, 86% of subjects with one or more post-COVID-19 DGBI had at least one GI symptom during the acute phase of COVID-19, while 14% did not. Depression (65%), but not anxiety (48%), was significantly more common in those with post-COVID-19 DGBI. CONCLUSION: GI symptoms are associated with a severe COVID-19 among survivors. Long-haulers may develop post-COVID-19 DGBI. Psychiatric disorders are common in post-COVID-19 DGBI.

STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery.

INTRODUCTION: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. METHODS: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. RESULTS: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. CONCLUSION: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery.

Coronavirus: Pure Infectious Disease or Genetic Predisposition.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes novel coronavirus disease (COVID-19), is the seventh pathogenic coronavirus recently discovered in December 2019 in Wuhan, China. To date, our knowledge about its effect on the human host remains limited. It is well known that host genetic factors account for the individual differences in the susceptibility to infectious diseases. The genetic susceptibility factors to COVID-19 and its severity are associated with several unanswered questions. However, the experience gained from an earlier strain of coronavirus, SARS-CoV-1, which shows 78% genetic similarity to SARS-CoV-2 and uses the same receptor to bind to host cells, could provide some clues. It, therefore, seems possible to assemble new evidence in order to solve a potential genetic predisposition puzzle for COVID-19. In this chapter, the puzzle pieces, including virus entry receptors, immune response, and inflammation-related genes, as well as the probable genetic predisposition models to COVID-19, are discussed.

Factors associated with COVID-19 severity and mortality among Hispanic patients living on the USA-Mexico border.

COVID-19 has ravaged the medical, social, and financial landscape across the world, and the USA-Mexico border is no exception. Although some risk factors for COVID-19 severity and mortality have already been identified in various ethnic cohorts, there remains a paucity of data among Hispanics, particularly those living on borders. Ethnic disparities in COVID-19 outcomes in Hispanic and black populations have been reported. We sought to identify the clinical presentation, treatment, laboratory, and imaging characteristics of 82 Hispanic patients in a county hospital and describe the factors associated with rates of hospitalization, intensive care unit (ICU) admission, and mortality. The most common comorbidities were hypertension (48.8%) and diabetes mellitus (DM) (39%), both found to be associated with hospitalization and mortality, while only DM was associated with increased rate of ICU admission. Multivariable analysis showed that individuals with fever, low oxygen saturation (SpO2), nasal congestion, shortness of breath, and DM had an increased risk of hospitalization. Individuals with fever, decreased levels of SpO2, and advanced age were found to be associated with an increased risk of death. The most common cause of death was respiratory failure (28.9%), followed by shock (17.8%) and acute kidney injury (15.6%). Our findings are critical to developing strategies and identifying at-risk individuals in a Hispanic population living on borders. Research aiming to identify key evidence-based prognostic factors in our patient population will help inform our healthcare providers so that best interventions can be implemented to improve the outcomes of patients with COVID-19.

Gastric Electrical Stimulation for Treatment of Refractory Gastroparesis: the Current Approach to Management.

PURPOSE OF REVIEW: Gastroparesis is one of the more challenging entities in the landscape of gastroenterology, posing difficulties for both patients and physicians with regard to effective management and therapies. In this article, we reviewed various gastroparesis treatment options, with an emphasis on gastric electrical stimulation (GES). RECENT FINDINGS: GES has demonstrated a significant reduction of cardinal symptoms in refractory gastroparetic patients, particularly nausea and vomiting, across multiple studies. However, GES has not been shown to conclusively decrease gastric emptying time in these patients. Such finding has led the investigators to analyze the impact of combining GES with pyloroplasty. While this treatment pathway is nascent, its results thus far reveal an amplified improvement of gastroparesis symptomatology in addition to significant reduction of gastric transit, compared to GES by itself. Limited treatment choices are available for refractory gastroparesis. Combining GES with pyloroplasty holds promise but requires further assessment in large-scale trials to fully evaluate the risks and benefits.

Plasma endocannabinoids and cannabimimetic fatty acid derivatives are altered in gastroparesis: A sex- and subtype-dependent observation.

BACKGROUND: Gastroparesis (GP) is a motility disorder of the stomach presenting with upper gastrointestinal symptoms in the setting of delayed gastric emptying. Endocannabinoids are involved in the regulation of GI function including motility. However, their role in the pathophysiology of GP has not been sufficiently investigated. Our goal was to compare the circulating levels of endocannabinoids and cannabimimetic fatty acid derivatives in GP versus control subjects. METHODS: The study compared plasma concentrations of endocannabinoids and their lipoamine and 2-acyl glycerol congeners, measured by high-pressure liquid chromatography/tandem mass spectrometry (HPLC-MS-MS), in adult patients with diabetic gastroparesis (DM-GP; n = 24; n = 16 female), idiopathic gastroparesis (ID-GP; n = 19; n = 11 female), diabetic patients without GP (DM; n = 19; n = 10 female), and healthy controls (HC; n = 18; n = 10 female). Data, presented as mean ± SEM, were analyzed with ANOVA (Sidak post hoc). KEY RESULTS: Endocannabinoids anandamide (AEA: 0.5 ± 0.1 nMol/L) and 2-arachidonoyl glycerol (2-AG: 2.6 ± 0.7 nMol/L) were significantly lower in female DM-GP patients vs. DM females (AEA: 2.5 ± 0.7 nMol/L and 2-AG: 9.4 ± 3.3 nMol/L). Other monoacylglycerols including 2-palmitoyl glycerol and 2-oleoyl glycerol were also lower in female DM-GP patients compared to DM females. No changes were observed in men. CONCLUSIONS & INFERENCES: Endocannabinoids and other fatty acid derivatives with cannabimimetic properties are reduced in female DM-GP patients. Since GP, particularly with diabetic etiology, is more prevalent among women and since cannabinoids are antiemetic, this decrease in levels may contribute to symptom development in these subjects. Targeting the endocannabinoid system may be a future therapeutic option in DM-GP patients.

Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy.

BACKGROUND: Retrograde single balloon enteroscopy (SBE) is a minimally invasive procedure which is less frequently performed compared with antegrade SBE. There are few studies on the retrograde through-the-scope enteroscopy (TTSE), a novel technique for evaluation of the small bowel. AIM: To compare the clinical utility and safety of retrograde TTSE with retrograde SBE. METHODS: Clinical data and complications of retrograde TTSE (2014-2018) and retrograde SBE (2011-2018) performed in a community hospital were reviewed and presented as mean ± SD or frequency (%) and compared using proper statistical tests. Technical success was defined as insertion of the enteroscope > 20 cm beyond ileocecal valve. RESULTS: Data obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied. The most common indication for retrograde enteroscopy was iron deficiency anemia (41 patients) followed by gastrointestinal bleeding (37 patients), and chronic diarrhea (7 patients). The duration of retrograde SBE procedure (91.9 ± 34.2 min) was significantly longer compared with retrograde TTSE (70.5 ± 30.7 min) (P = 0.04). Technical success was comparable in TTSE [23/27 (85.2%)] and SBE [41/54 (75.9%) (P = 0.33)]. The mean depth of insertion beyond the ileocecal valve in retrograde SBE (92.5 ± 70.0 cm) tended to be longer compared with retrograde TTSE (64.6 ± 49.0 cm) (P = 0.08). No complication was observed in this study. CONCLUSION: Both retrograde TTSE and retrograde SBE are feasible and safe. Retrograde TTSE takes a shorter time and has a comparable technical success with SBE. TTSE has a lower capacity of small bowel insertion.

Cannabinoid hyperemesis syndrome: definition, pathophysiology, clinical spectrum, insights into acute and long-term management.

Although cannabinoid hyperemesis syndrome (CHS) was first reported more than 15 years ago, it still remains an unfamiliar clinical entity among physicians worldwide. CHS is categorized by Rome IV classification as a functional gastroduodenal disorder. It is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, with cycles decreasing by the cessation of cannabis. CHS is also associated with abdominal pain reduced by hot baths and showers with comparative well-being between attacks. Thus, its clinical presentation resembles 'classic' cyclic vomiting syndrome, but eliciting a cannabis history is crucial in diagnosing this entity. In acute attacks, parenteral benzodiazepines are very effective. For prevention and long-term management, tricyclic antidepressants such as amitriptyline are the mainstay of therapy requiring doses in the range of 50-200 mg/d to achieve symptom control. In addition, counseling to achieve marijuana cessation, accompanied by antianxiety medications, is necessary for sustaining clinical outcomes. Once the patient is in remission and off marijuana for a period of 6-12 months, then tapering the dose of amitriptyline can be implemented, with the goal of no therapy being achieved in the majority of patients over time. With the legalization of marijuana in many states, CHS will become an increasingly prevalent clinical entity, so educating about CHS is an important goal, particularly for emergency department physicians who generally first encounter these patients.

Endoscopic pancreatic necrosectomy in the United States-Mexico border: A cross sectional study.

BACKGROUND: A recent expert panel issued recommendations about the technical aspects of direct endoscopic necrosectomy (DEN) for pancreatic walled-off necrosis (WON). However, significant technical heterogeneity still exists among endoscopists. AIM: To report the outcomes of our DEN technique and how it differs from a recent expert consensus statement and previous studies. METHODS: Medical records of patients with WON who underwent DEN from September 2016 - May 2019 were queried for the following information: Age, gender, ethnicity, etiology of acute pancreatitis, WON location and size, DEN technical information, adverse events (AEs) and outcomes. Adverse events were graded according to the American Society of Gastrointestinal Endoscopy Lexicon grading system. Technical success was defined as adequate lumen apposing metal stent (LAMS) deployment plus removal of ≥ 90% of necrosum. Clinical success was defined as complete resolution of WON cavity by imaging and resolution of symptoms at ≤ 3 months (mo) after last DEN. Data analysis was performed using mean and standard deviation for continuous variables, frequency and proportion for categorical variables, and median and range for interval data. RESULTS: A total of 21 patients underwent DEN. Most of them were Hispanic and their mean age was 51 ± 17 years. The majority of the collections were located in the body of the pancreas and the mean size was 13 cm ± 5 cm. The most common indication was persistent vomiting. Antibiotics were administered only in cases of infected necrosis. All LAMS were placed without radiological guidance, dilated the same day of deployment and removed after a mean of 27 ± 11 d. Routine cross-sectional imaging immediately after drainage was not performed. The mean interval between DEN sessions was 7 ± 4 d and the mean number of DEN/patient was 3 ± 2. Technical and clinical success rates were both 95%. AEs were seen in 5 patients and included: Sepsis (2), stent migration (1), stent maldeployment (1), perforation (1). The sensitivity and positive predictive value of an occluded LAMS leading to sepsis was 50% and 0.11 respectively. No fatalities were observed. CONCLUSION: Our DEN technique differed significantly from the one recommended by a recent expert panel and the one published in previous studies. Despite these differences excellent clinical outcomes were obtained.

Central Nervous System Mechanisms of Nausea in Gastroparesis: An fMRI-Based Case-Control Study.

BACKGROUND/AIMS: Nausea is a major complaint of gastroparesis (GP), and the pathophysiology of this condition is poorly understood. Therefore, this study utilized fMRI to investigate the possible central nervous system (CNS) mechanisms of nausea in 10 GP patients versus 8 healthy controls (HCs). METHODS: Nausea severity was assessed on a 0-10 scale and presented as mean ± SD. Nausea was increased from baseline utilizing up to 30 min of visual stimulation (VS). Functional network connectivity was measured with fMRI at baseline and after 30 min of VS. fMRI data were preprocessed using statistical parametric mapping software. Thirty-four independent components were identified as meaningful resting-state networks (RSNs) by group independent component analysis. The Functional Network Connectivity (FNC) among 5 RSNs considered important in CNS nausea mechanisms was calculated as the Pearson's pairwise correlation. RESULTS: Baseline nausea score in GP patients was 2.7 ± 2.0 and increased to 7.0 ± 1.5 after stimulation (P < 0.01). In HCs nausea scores did not increase from baseline after stimulus (0.3 ± 0.5). When comparing GP patients to HCs after VS, a significant reduction (P < 0.001) in bilateral insula network connectivity compared to the right insula network was detected. No significant differences in connectivity were noted among the other RSNs. Additionally, the average gray matter volume was non-significantly reduced in the insula in GP patients compared to HC. CONCLUSIONS: The insula connectivity network is impaired in nauseated GP patients. This phenomenon could explain the susceptibility of GP patients to nausea or may have resulted from a state of chronic nausea.