Characteristics of patients who underwent gastric electrical stimulation vs. surgical pyloric interventions for refractory gastroparesis.

BACKGROUND: There has been recent debate comparing the efficacy of gastric electrical stimulation (GES) with pyloric intervention, but medical literature lacks clear indications for when to perform GES or pyloric intervention. This study aims to assess the effect of sociodemographic factors and hospital characteristics on the surgical technique chosen for the treatment of gastroparesis. METHODS: Data was extracted from the National Inpatient Sample between the years 2012 and 2014, using any discharge diagnosis of gastroparesis. For comparison of analysis between GES and pyloric surgical intervention, pyloroplasty, endoscopic pyloric dilation, and pyloromyotomy were considered to be pyloric interventions. The study population was divided into two groups, one which received GES and the other receiving pyloric intervention, to compare socioeconomic factors and hospital characteristics. RESULTS: In total, 737,930 hospitalizations had a discharge diagnosis of gastroparesis between 2012 and 2014. On weighted multivariant analysis of patients undergoing GES or pyloric intervention for gastroparesis, being female (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.25-1.78; P < 0.001), being Hispanic (OR 1.75, 95%CI; P < 0.001), being in urban teaching (OR 1.41, 95%CI 1.15-1.72; P < 0.001), and nonteaching hospitals (OR 2.93, 95%CI 2.4-3.58; P < 0.001), early satiety (OR 6.70, 95%CI 1.54-31.25; P = 0.01), and diabetes mellitus (OR 2.14, 95%CI 1.78-2.56; P < 0.001) were each statistically significantly correlated with receiving GES intervention compared to pyloric intervention. CONCLUSION: The racial difference, payer source, and hospital location affected the surgical intervention (GES or pyloric intervention) that patients with gastroparesis would receive.

Gastric Electrical Stimulation Has an Effect on Gastric Interstitial cells of Cajal (ICC) That is Associated With Mast Cells.

Introduction Gastric electrical stimulation (GES) is an emerging therapy for gastric motility disorders, showing improvement of gastroparesis related symptoms in previous studies. Interstitial cells of Cajal (ICC) and mast cells have been shown to have a relevant role in gastroparesis pathogenesis. However, the exact effects of GES in those cells is relatively unknown. Methods Full thickness biopsies (FTBx) of 20 patients with refractory gastroparesis were obtained at the time of GES placement and repeated when the device was exchanged (mean of 22.5 months between biopsies). A patient-reported outcomes survey was obtained during each office visit during this period. All biopsies were stained with cluster of differentiation 117 (CD117), S100, and mast cell tryptase antibodies and were analyzed. Results Half of the patients had a significant increase of ICC during the repeated biopsy compared with baseline (p=0.01) and the other half had significant decrease in ICC levels (p=0.006) but there was no noticeable difference in mast cells counts at baseline between groups. Mast cells analysis was performed in two different groups depending on ICC change from the baseline biopsy (CD117 increase vs CD117 decrease). There was only a significant increase of mast cells count within the CD117 worsened ICC group (p=0.007). Conclusion No significant increase in the number of mast cells count seen in patients who received a GES may indicate an improvement in overall inflammation in patients with refractory gastroparesis after GES placement.

High-resolution Mapping of Hyperglycemia-induced Gastric Slow Wave Dysrhythmias

BACKGROUND/AIMS: It is now recognised that gastric dysrhythmias are best characterised by their spatial propagation pattern. Hyperglycemia is an important cause of gastric slow wave dysrhythmia, however, the spatiotemporal patterns of dysrhythmias in this context have not been investigated. This study aims to investigate the relationship between hyperglycemia and the patterns of dysrhythmias by employing high-resolution (multi-electrode) mapping simultaneously at the anterior and posterior gastric serosa. METHODS: High-resolution mapping (8 × 16 electrodes per serosal) was performed in 4 anesthetized hounds. Baseline recordings (21 ± 8 minutes) were followed by intravenous injection of glucagon (0.5 mg per dose) and further recordings (59 ± 15 minutes). Blood glucose levels were monitored manually using a glucose sensing kit at regular 5-minute intervals. Slow wave activation maps, amplitudes, velocity, anisotropic ratio, and frequency were calculated. Differences were compared between baseline and post glucagon injection. RESULTS: Baseline slow waves propagated symmetrically and antegrade. The blood glucose levels were increased by an average of 112% compared to the baseline by the end of the recordings. All subjects demonstrated elevated incidence of slow wave dysrhythmias following injection compared to the baseline (48 ± 23% vs 6 ± 4%, P < 0.05). Dysrhythmias arose simultaneously or independently on anterior and posterior serosa. Spatial dysrhythmias occurred before and persisted after the onset and disappearance of temporal dysrhythmias. CONCLUSIONS: Infusion of glucagon induced gastric slow wave dysrhythmias, which occurred across a heterogeneous range of patterns and frequencies. The spatial dysrhythmias of gastric slow waves were shown to be more prevalent and persisted over a longer period of time compared to the temporal dysrhythmias.

Management of Upper Gastrointestinal Bleeding by an Internist.

Nonvariceal upper gastrointestinal bleeding (UGIB) carries high morbidity and mortality, which can be lowered by timely evaluation and management. This article presents a comprehensive literature review and current guidelines for the management of nonvariceal UGIB by an internist. Pre-endoscopic management includes optimal resuscitation, and making a decision about holding the anticoagulation and antiplatelet therapy versus continuation due to risk of thrombosis. Proton pump inhibitors (PPIs) are beneficial for both ulcer and nonulcer diseases as they reduce the risk of re-bleeding by clot stabilization. Endoscopy should only be performed after hemodynamic stability has been achieved and should not be delayed by more than 24 hours. Resumption of anticoagulation and antiplatelet therapy is based on endoscopic findings and thromboembolic risk. The patient should be discharged on PPIs and should be followed up by a primary care physician.

Gastroparesis Updates on Pathogenesis and Management

Gastroparesis (Gp) is a chronic disease that presents with clinical symptoms of early satiety, bloating, nausea, vomiting, and abdominal pain. Along with these symptoms, an objective finding of delayed gastric emptying, along with a documented absence of gastric outlet obstruction, are required for diagnosis. This article focuses on updates in the pathogenesis and management of Gp. Recent studies on full thickness biopsies of Gp patients have shed light on the complex interactions of the central, autonomic, and enteric nervous systems, which all play key roles in maintaining normal gut motility. The management of Gp has evolved beyond prokinetics and antiemetics with the use of gastric electrical stimulators (GES). In addition, this review aims to introduce the concept of gastroparesis-like syndrome (GLS). GLS helps groups of patients who have the cardinal symptoms of Gp but have a normal or rapid emptying test. Recent tests have shown that patients with Gp and GLS have similar pathophysiology, benefit greatly from GES placement, and likely should be treated in a similar manner.

Gastroparesis Updates on Pathogenesis and Management

Gastroparesis (Gp) is a chronic disease that presents with clinical symptoms of early satiety, bloating, nausea, vomiting, and abdominal pain. Along with these symptoms, an objective finding of delayed gastric emptying, along with a documented absence of gastric outlet obstruction, are required for diagnosis. This article focuses on updates in the pathogenesis and management of Gp. Recent studies on full thickness biopsies of Gp patients have shed light on the complex interactions of the central, autonomic, and enteric nervous systems, which all play key roles in maintaining normal gut motility. The management of Gp has evolved beyond prokinetics and antiemetics with the use of gastric electrical stimulators (GES). In addition, this review aims to introduce the concept of gastroparesis-like syndrome (GLS). GLS helps groups of patients who have the cardinal symptoms of Gp but have a normal or rapid emptying test. Recent tests have shown that patients with Gp and GLS have similar pathophysiology, benefit greatly from GES placement, and likely should be treated in a similar manner.

Temporary Endoscopic Stimulation in Gastroparesis-like Syndrome

BACKGROUND/AIMS: Gastroparesis-like syndrome (GLS) is defined as gastroparesis-like symptoms with normal gastric scintigraphy. While the efficacy of gastric electrical stimulation (GES) in gastroparesis is well known, the utility of GES in GLS is largely unknown. Our aim was to clarify the role of GES in GLS. We implanted consecutive patients with symptoms of gastroparesis with temporary gastric electrical stimulation and observed changes in gastric scintigraphy and total symptom score. METHODS: Five hundred and fifty-one patients suffering from symptoms of gastroparesis (nausea, vomiting, bloating/distension, anorexia/early satiety, and abdominal pain) with negative endoscopy underwent gastric scintigraphy with analysis of 1) solid radio-nuclide gastric emptying at 1, 2, and 4 hours (% remaining); 2) area under the gastric emptying curve (AUC) at 1, 2, and 4 hours; and 3) total gastric emptying test (GET) (the sum of 1, 2, and 4 hour values). Patients were stratified into: delayed gastric emptying, normal gastric emptying, and rapid gastric emptying (Appendix). Of the 551 patients in the larger cohort, 379 had implantation of temporary gastric electrical stimulation (tGES). Gastrointestinal symptoms and gastric emptying were com -pared pre and post tGES implantation. RESULTS: After tGES, 2 hour gastric retention decreased (P < 0.01) for the delayed patients, and increased (P < 0.001) for normal and rapid patients. These changes were accompanied by improvements (P < 0.001) in vomiting, nausea, and total symptom scores in all 3 subgroups. CONCLUSIONS: Gastric electrical stimulation may be an effective therapy for treating the symptoms of gastroparesis with normal gastric emptying. Further exploration of endoscopic electrical stimulation as a treatment for gastroparesis-like symptoms with non-delayed gastric emptying is needed.