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In a very welcome article, Vosoughi and colleagues1 describe the experience from five tertiary centres (four in the USA, one in Brazil) regarding the outcomes of the gastric peroral endoscopic myotomy (G-POEM) procedure for the treatment of 80 patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying (gastric retention >20% at 4 hours). The primary endpoint was clinical success, defined as at least one score decrease in the Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales at 12 months. From this open-label, uncontrolled experience, the authors concluded that G-POEM was only modestly effective in patient with gastroparesis, with a clinical success rate of 56% at 12 months. However, serial assessment documented that the response to G-POEM was durable over the 12-month follow-up. This study also identified that baseline GCSI score >2.6 and baseline gastric retention greater than 20% at 4 hours, as well as responsiveness 1 month after the G-POEM procedure were independent predictors of clinical success 12 months after G-POEM. The study has many strengths including the sample size of 80, of which 94% had completed 12-month follow-up, use of the validated GCSI score and subscales, and assessment of quality of life, using the 36-Item Short Form Questionnaire, at baseline and 1, 3, 6 …

Background. It has been proved that pupils with thyroid diseases, in particular diffuse nontoxic goiter (DNG), suffer from digestive disorders almost 2.5 times more often. The purpose was to study the features of gastric emptying in children with diffuse nontoxic goiter. Materials and methods. The main group included children with DNG (n = 89), the comparison group — children without thyroid diseases (n = 84). A multi-faceted questionnaire survey, thyroid ultrasonography and functional ultrasonography of the stomach were conducted. Results. The prevalence of goiter among children of Bukovina was 53.3 %. The frequency of functional gastrointestinal disorders in children of both groups was 27.55 ± 2.17 %: in patients with DNG — 33.9 ± 2.3 %, in children without DNG — 21.4 ± 1.3 %, p < 0.05. Impaired gastric emptying was detected in 12 patients with DNG (11.6 %) and in 6 (8.5 %) children without DNG. Most often, these violations were registered in patients with functional dyspepsia. Conclusions. A significantly higher frequency of functional gastrointestinal disorders in children with diffuse nontoxic goiter, including impaired gastric emptying, was established. Treatment of somatic disease will reduce the frequency of unfavorable course of DNG in children and adolescents., Актуальность. Доказано, что почти в 2,5 раза чаще патологией органов пищеварения страдают школьники с болезнями щитовидной железы, в том числе с диффузным нетоксическим зобом (ДНЗ). Цель: изучить особенности моторно-эвакуаторной функции желудка у детей с диффузным нетоксическим зобом. Материалы и методы. Основную группу составили дети с зобом (89 человек), группу сравнения — дети (84 человека) без отклонений со стороны щитовидной железы. Проводилось многоплановое анкетирование, ультрасонографическое исследование щитовидной железы и функциональное ультрасонографическое исследование желудка. Результаты. Распространенность зоба среди детей Буковины составила 53,3 %. Частота функциональных расстройств органов пищеварения у детей обеих групп составляла 27,55 ± 2,17 %: у детей с ДНЗ — 33,9 ± 2,3 %, у детей без ДНЗ — 21,4 ± 1,3 %, p, Актуальність. Доведено, що майже у 2,5 раза частіше від патології органів травлення страждають школярі з хворобами щитоподібної залози, зокрема з дифузним нетоксичним зобом (ДНЗ). Мета: вивчити особливості моторно-евакуаторної функції шлунка в дітей із дифузним нетоксичним зобом. Матеріали та методи. Основну групу становили діти із зобом (89 осіб), групу порівняння — діти без відхилень з боку щитоподібної залози (84 особи). Проводилось багатопланове анкетування, ультрасонографічне дослідження щитоподібної залози й функціональне ультрасонографічне дослідження шлунка. Результати. Поширеність зоба серед дітей Буковини становила 53,3 %. Частота функціональних розладів органів травлення в дітей обох груп становила 27,55 ± 2,17 %: у дітей із ДНЗ — 33,9 ± 2,3 %, у дітей без ДНЗ — 21,4 ± 1,3 %, p < 0,05. Порушення моторно-евакуаторної функції шлунка встановлені у 12 дітей із ДНЗ (11,6 %) і 6 (8,5 %) дітей без ДНЗ. Найчастіше ці порушення реєструвалися в дітей із функціональною диспепсією. Висновки. Встановлено вірогідно вищу частоту функціональних розладів травної системи в дітей із дифузним нетоксичним зобом, у тому числі порушень моторно-евакуаторної функції шлунка. Санація соматичної патології дозволить зменшити частоту несприятливого перебігу ДНЗ у дітей і підлітків.

Results: Impaired gastric emptying is observed in long-standing diabetic patients. To date, there is limited information on cardiovascular events in diabetic subjects with upper gastrointestinal (UGI) symptoms according to the presence of impaired gastric emptying. The aim of this study was to identify cardiovascular events after gastric emptying study in diabetic subjects with UGI symptoms. This study collected data from 160 diabetic subjects (23 with type 1 diabetes and 137 with type 2 diabetes) with UGI symptoms who had undergone gastric emptying scintigraphy from 2001 to 2016. We gathered data on the incidence of cardiovascular events (coronary heart disease and ischemic stroke) after gastric emptying study. There were 66 diabetic subjects with normal gastric emptying and 94 diabetic subjects with impaired gastric emptying (58 with delayed gastric emptying and 36 with rapid gastric emptying). During 7.5 years of follow-up, 22.5% of subjects (36/160) developed the cardiovascular events (19 with coronary heart disease, 12 with ischemic stroke and 5 with both). The incidence of coronary heart disease was higher in the subjects with impaired gastric emptying (4.2% at 1 year, 10.6% at 3 years, and 12.7% at 5 years) than those with normal gastric emptying (2.4% at 1 year, 3.6% at 3 years and 4.8% at 5 years p=0.039). Our results showed that diabetic subjects with impaired gastric emptying had higher incidence of coronary heart disease than those with normal gastric emptying. This study may warrant a more careful cardiovascular assessment with a high index of suspicion for possible events in management of diabetic subjects with impaired gastric emptying. Disclosure S. Park: None. J. Chung: None. D. Cho: None. D. Chung: None. M. Chung: None.

Despite the large body of evidence supporting adequate early enteral nutrition (EN) in surgical patients, iatrogenic underfeeding is common. Myths and misconceptions persist and patients may receive suboptimal nutritional therapy as a result of outdated or uninformed practices. EN is safe and potentially beneficial in patients requiring vasopressor support. Early feeding proximal to a “fresh” anastomosis is safe. Routine monitoring of gastric residual volume (GRV) for tube feeding intolerance is no longer recommended, and routine post-pyloric feeding in patients without evidence of impaired gastric emptying does not lower the risk of aspiration. Awaiting the return of flatus before initiating post-operative feeding is not required. Albumin is not an accurate marker of nutritional adequacy in the hospital setting. Permissive underfeeding may not be beneficial for malnourished surgical patients. This article addresses myths and misconceptions of enteral nutrition in surgical patients.

Acotiamide hydrochloride is a novel upper gastrointestinal (GI) motility modulator and stress regulator currently being developed for the treatment of functional dyspepsia (FD). The mechanism underlying the enhancement of GI motility by this agent has been proposed to be based on its muscarinic antagonism and inhibitory effects on acetylcholinesterase activity. Pathophysiological studies showed that acotiamide significantly improved both delayed gastric emptying and feeding inhibition in restraint stress-induced model, but did not affect both normal gastric emptying and feeding in intact animals, indicating that acotiamide exerted effects only on the impaired gastric emptying and feeding behavior. According to the clinical pilot study in Europe, acotiamide, at the dose of 100 mg t.i.d., showed to improve the symptoms and quality of life of patients with FD, indicating the need for larger scale symptomatic studies on the efficacy of acotiamide in patients with FD. The recent phase II studies conducted in Japan presented in this issue of the journal also confirmed that acotiamide, at the optimal dose of 100 mg, has potential therapeutic efficacy, especially for meal-related FD symptoms. Although a phase III study is on going, acotiamide is now expected as a novel treatment option for FD.

INTRODUCTION Bezoars are retained concretions of animal or vegetable material in the gastrointestinal tract. Most bezoars reside in the stomach, but they may be encountered elsewhere. Previous gastric surgery, which has resulted in impaired gastric emptying and/or decreased acid production, is usually the cause of bezoars. Phytobezoars are more common, while trichobezoars are rare. Endoscopy and gastrografin swallow may aid in diagnosis. The treatment of bezoars can be either conservative or surgical. METHODS After searching the computerized medical database, all files of hospitalized patients in the years 1992 to 2002 with the diagnoses "bezoars," "phytobezoars," and "tricobezoars" were evaluated. RESULTS Eighteen patients had bezoars: 16 had phytobezoars and 2 patients were diagnosed as having trichobezoars. Eleven of the patients had previous gastric operation. All patients but one were treated surgically. Two unusual cases of trichobezoar are presented here. DISCUSSION Thorough understanding of bezoars can allow the clinician to be especially alert when dealing with those patients most likely to develop them, and thus diagnose the condition at an early stage.

Objective To evaluate if impaired gastric emptying of digestible solids can explain the disturbed eating behavior in continuous ambulatory peritoneal dialysis (CAPD) patients, and if predialytic and dialytic (CAPD and hemodialysis) patients with impaired gastric emptying have a higher prevalence of electrogastrographic (EGG) abnormalities. Design Cross-sectional study. After ingestion of a 99mTc-labeled test meal, anterior and posterior 1-minute scintigraphic acquisitions were collected every 5 minutes during the first 50 minutes and thereafter every 10 minutes until 2 hours had elapsed. Simultaneously, cutaneous EGG recorded gastric myoelectric activity. Setting The Division of Nephrology and the Department of Nuclear Medicine at the same academic teaching hospital. Participants Thirty outpatients participated in both the gastric emptying and the EGG studies. Dialysis patients should have been on dialysis for more than 3 months. For comparison, 160 healthy control subjects participated in the gastric emptying study. Main Outcome Measures The following parameters were used to describe gastric emptying: lag phase 90%, half-emptying time ( T50), gastric retention at 90 and 120 minutes (Ret 90/120) and gastric emptying rate (GER, %/min). Electrogastrographic measurements were expressed as percentages of normal slow waves [2.4 – 3.6 cycles/min (cpm)], bradygastria (1.5 – 2.4 cpm), and tachygastria (3.6 – 10 cpm). Results T50 was prolonged, Ret 90 and Ret 120 were higher, and GER was slower in male CAPD patients compared to male controls. No significant differences were found in postprandial EGG. Conclusion Gastric emptying is impaired in male non-diabetic CAPD patients. However, abnormalities in postprandial EGG cannot explain this finding.

It is now well recognized that the prevalence of delayed gastric emptying in both insulin-dependent as well as noninsulin-dependent diabetes mellitus is high. Recently performed studies have shown that motor disorders of several parts of the upper gastrointestinal tract contribute to this delay in gastric emptying. Traditionally, disordered motility in diabetes mellitus has been attributed to irreversible autonomic nerve damage. However, recent observations indicate that hyperglycemia causes a reversible impairment of motility in various regions of the gastrointestinal tract. Upper gastrointestinal symptoms are highly prevalent in diabetes mellitus. These dyspeptic symptoms are not only induced by delayed gastric emptying, but altered visceroperception also plays a role in the genesis of dyspeptic symptoms. There is increasing evidence that impaired gastric emptying influences glycemia control, but the clinical consequences of these observations need further investigation. At present dyspeptic symptoms form the rationale for the treatment of delayed gastric emptying with prokinetic drugs.

To measure gastric emptying in critically ill patients using an acetaminophen absorption model and determine which variables are associated with impaired gastric emptying.A prospective, cohort study.A medical/surgical ICU at a tertiary care hospital: Hamilton General Hospital, Hamilton, Ontario.We recruited 72 mechanically ventilated patients expected to remain in the ICU for more than 48 h. Our results were compared to those in healthy volunteers.Within 48 h of admission to the ICU, 1.6 g acetaminophen suspension were administered via a nasogastric tube into the stomach. Blood samples were drawn a t = 0, 30, 60, 90, and 120 min for measurement of plasma acetaminophen levels determined by the enzymatic degradation method.Maximal concentration of acetaminophen was 94.1 (75.3) mumol/l compared to 208.4 (33.1) mumol/l in a control population (p0.0001). The time to reach the maximal concentration was 105 min (60-180) compared to 30 min (15-90) in controls (p0.0001). The area under the time-acetaminophen concentration curve t = 120 was 9301 (7343) mumol/min per l compared to 11644 (1336) mumol/min per l in the controls (p = 0.28). The variables associated with delayed gastric emptying were age, sex and use of opioids for analgesia and sedation.Gastric emptying is delayed in critically ill patients. The important consequences of this phenomenon include intolerance to enteral nutrition and gastric colonization. Strategies to minimize the use of narcotics may improve gastric emptying. Studies to examine the effect of gastrointestinal prokinetic agents on gastric emptying are needed.

Background: Several factors, such as dysphagia, an increased motor activity, increased metabolic rate and a hypermetabolic state have been discussed as contributing to weight loss even at the early stages of Huntingtons Disease (HD). Aim of this pilot study was to investigate gastric emptying as a possible reason for weight loss in HD. Methods: 11 HD participants at early stages of the disease and matched controls were investigated by using the well-established and non-invasive 13C-octanoate breath test. TheGastroparesis Cardinal Symptom Indexand theShort-Form Leeds Dyspepsia Questionnairewere used for clinical evaluation of gastroparesis or dyspepsia. Abstract Background: Several factors, such as dysphagia, an increased motor activity, increased metabolic rate and a hypermetabolic state have been discussed as contributing to weight loss even at the early stages of Huntingtons Disease (HD). Aim of this pilot study was to investigate gastric emptying as a possible reason for weight loss in HD. Methods: 11 HD participants at early stages of the disease and matched controls were investigated by using the well-established and non-invasive 13C-octanoate breath test. TheGastroparesis Cardinal Symptom Indexand theShort-Form Leeds Dyspepsia Questionnairewere used for clinical evaluation of gastroparesis or dyspepsia. Abstract Background: Several factors, such as dysphagia, an increased motor activity, increased metabolic rate and a hypermetabolic state have been discussed as contributing to weight loss even at the early stages of Huntingtons Disease (HD). Aim of this pilot study was to investigate gastric emptying as a possible reason for weight loss in HD. Methods: 11 HD participants at early stages of the disease and matched controls were investigated by using the well-established and non-invasive 13C-octanoate breath test. TheGastroparesis Cardinal Symptom Indexand theShort-Form Leeds Dyspepsia Questionnairewere used for clinical evaluation of gastroparesis or dyspepsia.

Background/Aims: In this crossover study, we investigated whether nizatidine, a H2-receptor antagonist, can alleviate clinical symptoms and gastric emptying in patients with Rome III-based functional dyspepsia (FD) with or without impaired gastric emptying. Methods: We enrolled 30 patients presenting with FD symptoms (epigastric pain syndrome, n = 6; postprandial distress syndrome, n = 24). Rome III-based FD patients were treated with nizatidine (300 mg/day) or placebo for 4 weeks in a crossover trial. Gastric motility was mainly evaluated with the Tmax value using the 13C-acetate breath test. Meal-related symptoms were defined as postprandial fullness and early satiation. Gastroesophageal symptom was defined as a burning feeling rising from the stomach or lower chest up toward the neck. Acylated- and desacylated ghrelin levels were evaluated by the ELISA method. Clinical symptoms, gastric emptying and ghrelin levels were evaluated at three different points during the study (pretreatment, after 4 weeks former treatment and after 4 weeks later treatment). The primary end point of this study was to determine whether nizatidine would improve clinical symptoms and gastric emptying in FD patients with or without impaired gastric emptying via affecting ghrelin levels. Results: Meal-related symptoms of the patients treated with nizatidine improved significantly (21/30; 70%) compared to those treated with placebo (3/30; 10%). In addition, nizatidine treatment also significantly improved gastroesophageal symptoms (16/30; 53%) compared to those treated with placebo (0/30; 0%). Nizatidine treatment in patients with FD accompanied by impaired gastric emptying significantly improved clinical symptoms and Tmax value as a marker of gastric emptying (10/11, 91%; 9/11, 82%) compared to placebo therapy, respectively. There were no significant differences in ghrelin levels between nizatidine treatment and placebo therapy. Conclusion: Nizatidine administration significantly improved both gastric emptying and clinical symptoms in FD patients with impaired gastric emptying.

Patients with functional dyspepsia and the irritable bowel syndrome are commonly seen in both primary care and gastroenterology subspecialty settings. Although functional dyspepsia and the irritable bowel syndrome can occur separately, recent research suggests that they often appear together as an overlap syndrome and thus may represent different portions of a unifying spectrum of disease. Despite their widespread prevalence, the pathogenesis of these disorders is not well established but may include impaired gastric emptying, gastric dysrhythmias, hypersensitivity (to acid exposure and to stretch), and Helicobacter pylori infection. Once other disorders in the differential diagnosis have been excluded, treatment of patients with functional dyspepsia, irritable bowel syndrome, and the overlap syndrome without alarm signs underscores current prevailing pathophysiologies and is generally empiric and symptom based. It is hoped that management of these disorders will become more targeted and efficacious as our understanding of them improves.

The relationship between functional dyspepsia and delayed gastric emptying of solids or liquids is still unclear. The aim of the present study was to investigate in dyspeptic patients the prevalence of delayed gastric emptying for solids or for liquids and to investigate the relationship to the dyspepsia symptom pattern.In 392 and 330 patients with functional dyspepsia, the solid and liquid gastric emptying, respectively, was measured using breath tests, and the severity of eight dyspeptic symptoms was scored.Gastric emptying of solids and liquids were delayed in 23% and 35% of the patients. Multivariate analysis showed that the presence of vomiting and postprandial fullness was associated with delayed solid emptying (OR 2.65, 95% CI = 1.62-4.35 and OR 3.08, 95% CI = 1.28-9.16, respectively). Postprandial fullness was also associated with the risk of delayed liquid emptying when symptom was present (OR 3.5, 95% CI = 1.57-8.68), relevant or severe (OR 2.504, 95% CI = 1.41-4.65), and severe (OR 2.214, 95% CI = 1.34-3.67). Severe early satiety was associated with the risk of delayed liquid emptying (OR 1.902, 95% CI = 1.90-3.30).A subset of dyspeptic patients has delayed gastric emptying of solids or of liquids. Delayed gastric emptying of solids was constantly associated with postprandial fullness and with vomiting. Delayed emptying for liquids was also associated with postprandial fullness and with severe early satiety.

Clinicians should consider impaired gastric emptying when evaluating patients with myotonic dystrophy type 1 and severe symptoms of upper gut dysmotility. Gastric emptying time measurement by radionuclide study, although informative, is rarely done in clinical practice.

The preferred method of nutritional support in intensive care patients is via the enteral feeding route due to its favourable trophic effects on the intestinal mucosa, reduced rate of complications and lower costs when compared with parenteral nutrition. Impaired gastric emptying can be a limiting factor in providing enteral nutrition, commonly affected by critical illness, and naso-jejunal tube feeding can be useful in patients who fail to tolerate naso-gastric tube feeding. Endoscopic placement of naso-jejunal tubes can be performed at the bedside, is highly successful, 85–90% success rate can be expected and enteral feeding can start immediately following the procedure.

The aim of our study was to measure the gastric emptying rate for a solid meal in diabetic patients who had no gastrointestinal complaints with (group 1, n = 12) or without (group 2, n = 10) cardiac autonomic neuropathy and in normal controls comparable in age and sex (group 3, n = 10). Gastric emptying rate was assessed with a sequential scintiscanning method. The percentages of the initial isotope activity remaining in the stomach at different times (20, 40, 60, 80, 100, and 120 min) after the ingestion of a Tc-99m-labeled test meal and the emptying half-time were calculated. Cardiac autonomic neuropathy was determined by the beat-to-beat variations in heart rate during deep breathing. A significant reduction of the gastric emptying rate was observed in group 1. Indeed, at 80, 100, and 120 min the percentage of residual isotope activity was 73 ± 4, 60 ± 6, and 50 ± 6% (mean ± SE), respectively, in group 1 versus 61 ± 3 (P < .05), 45 ± 4 (P < .05), and 32 ± 4% (P < .02) in group 2. In group 3, residual isotope activity was 57 ± 4 (P < .05 vs. group 1), 41 ± 4 (P < .05), and 29 ± 4% (P < .02), respectively. Emptying half-time was also longer in group 1 (121 ± 9 min) than in group 2 (95 ± 6 min, P < .05) or group 3 (90 ± 4 min, P < .02). For a given diabetic patient, there was no correlation between abnormal low gastric emptying and cardiac autonomic neuropathy. In conclusion, this study shows that in a group of diabetic patients with cardiac autonomic neuropathy, mean gastric emptying rate for solid meals is significantly impaired when compared with patients without cardiac autonomic neuropathy or normal controls, even when gastrointestinal symptoms are absent.

Eighty patients undergoing abdominal surgery were studied after operation. Morphine was administered regularly every 4 h by either the i.m. {morphine sulphate 10mg) or the oral route (MST Continus 20 mg) in a double-blind double-dummy trial. Both MST and i.m. morphine provided satisfactory postoperative analgesia, but significantly greater amounts of supplementary i.m. morphine were required in the MST group. More adverse effects were reported by the patients in the i.m. morphine group. The mean serum morphine concentration in 12 patients in the MST group was 1.7 ng ml-1 at 08.00 h and 19.5 ngml-1 at 16.00 h on the 1st day after operation, suggesting impaired gastric emptying in the early postoperative period. It is therefore recommended that further studies of the bioavail-ability of MST in the early postoperative period be undertaken before any recommendations are made regarding its routine use for pain relief at that time.

The mechanism of gastric stasis in disorders of gastrointestinal motility is largely unexplored. The region or regions of abnormal motility in 13 patients with a gastrointestinal motility disorder were characterized manometrically. Antral hypomotility was established in 6 patients and intestinal dysmotility in 7 others. One patient had both antral hypomotility and intestinal dysmotility. Gastric emptying of solids and liquids was quantitated scintigraphically; emptying data for solids were represented by a two-phase model (lag and emptying) and for liquids by a power exponential model. Antral hypomotility was associated with gastric stasis manifested by both a prolongation of the solid lag time [from 35 +/- 6 min for controls to 87 +/- 23 min (mean +/- SE), p less than 0.05] and slower emptying rates of solids (from a slope index of 29.9 +/- 2 for controls to 17.8 +/- 5, p less than 0.05) and liquids (from a kappa index of 3.6 +/- 0.6 for controls to 1.5 +/- 0.5, p less than 0.05). Intestinal dysmotility did not alter the solid lag time; however, it did decrease the slope of solid emptying from the stomach (from a slope index of 29.9 +/- 2 for controls to 13.5 +/- 3, p less than 0.05) and also prolonged emptying of liquids (from a kappa index of 3.6 +/- 0.3 for controls to 1.9 +/- 0.6, p less than 0.05). These data are consistent with the hypothesis that the gastric stasis in gut dysmotilities occurs because of impaired antral peristalsis due to antral hypomotility or increased resistance to flow into the small bowel due to intestinal dysmotility.

Vagotomy and pyloroplasty is an established operative procedure in the management of peptic ulceration.1As described by Kraft and Fry,2a wide, formal Finney pyloroplasty has been adopted as the drainage procedure of choice at the University of Michigan, as well as at other centers. Following vagotomy and Finney pyloroplasty, a distinct number of patients develop impaired gastric emptying as reported by Kraft et al.3This abnormality in gastric emptying occurs in the early postoperative period and has been ascribed to the physiologic effects of vagotomy. To our knowledge, no investigator has formally questioned the physiologic alterations induced by pyloroplasty. The main purpose of this study was to evaluate the effect of pyloroplasty on gastric antral and duodenal motility. Secondly, we also considered the effect of pyloroplasty plus vagotomy on contractile activity of the antral duodenal area. For these purposes, a series of dogs were chronically prepared

Diabetic autonomic neuropathy may result in delayed gastric emptying and gastric retention. A case of gastric phytobezoar formation that was secondary to diabetic autonomic neuropathy is reported. Greatly impaired gastric emptying was documented in this case by administration of a radiolabelled meal. Parenteral metoclopramide hydrochloride completely corrected the patient's gastric motility disturbance. ( Arch Intern Med 137:1729, 1977)