Gastric Emptying in Spinal Cord Injury Patients

Prolonged gastric emptying half-time (GET1/2)has been observed in several neurological disorders.However, findings of altered gastric emptying (GE) inprevious studies on subjects with spinal cord injuries (SCI) have been questioned. Thus, GET1/2 ofsolid meals in SCI patients was studied by radionuclideimaging. This prospective study was conducted to assessGET1/2 in 50 SCI patients using radionuclide labeled solid meals. GET1/2 was abnormal in 58% of the50 SCI patients. Age (abnormal GET1/2 in 57% of young vs59% of old patients) and injury duration (abnormalGET1/2 in 61% of long vs 56% of short duration patients) were not statistically significantfactors influencing GET1/2 (P > 0.05). However, theincidences of abnormal GET1/2 in female SCI patients(57%) and patients with high level injury (quadriplegic) (83%) were higher than in male SCI patients(47%) and patients with low level injury (paraplegic)(35%) (P < 0.05). SCI can cause significant prolongedGE of a solid meal, especially in female patients and patients with high level injury.     

Gastric Emptying Rates to Liquid or Solid Meals Appear to be Unaffected by Spinal Cord Injury

Objectives: There is controversy with regard to the effect of spinal cord injury (SCI) on gastric emptying times of liquids. The emptying rates of solids in subjects with SCI have not yet heen addressed. Thus, the gastric emptying rates for hoth liquids and solids were studied by radionuclide imaging in subjects with chronic SCI. Methods: After an overnight fast, subjects with SCI were evaluated for gastric emptying rates for iso-osmolar (normal saline) and hyperosmolar (glucose) liquids and a mixed meal of liquids and solids. Twenty-Hve subjects received normal saline (500 ml). Of these 25 subjects, 16 and 4 others (a total of 20 subjects) received 75 g glucose dissolved in 225 ml water. Each of the liquid meals was labeled with 300 μCi technetium-99-m-di-ethylenetriaminepenta-ascetic acid (^99mTc-DPTA). The mixed meal consisted of egg white labeled with 300 μCi technetium-99m-sulfur colloid (^99mTc-SC) between two slices of toast with water (110 ml). Each test meal was followed by anterior radionuclide imaging of the stomach with the subject seated. The results were compared with those of matched healthy nonSCI subjects from the literature. Results: Compared with gastric emptying times reported in the literature in healthy subjects without SCI, no significant differences were noted in those with SCI with regard to rates of gastric emptying for liquids (whether iso- or hyperosmolar) and for solids. Conclusions: Our findings do not support the previously reported results of a delay in gastric emptying for liquids in subjects with SCI. We have extended our findings of essentially normal rates of gastric emptying of liquids to that of solids.     

Bowel Dysfunction in Spinal Cord Injury

Purpose of Review

To evaluate and report current evidence regarding the management of bowel dysfunction in spinal cord injury. There is a paucity of high-quality large studies on which to base management advice.

Recent Findings

Recent research has focused on defining the nature of symptomatology of bowel dysfunction in SCI and describing the effects on quality of life and social interactions. Technical aspects of colonoscopy have received attention, and aspects of understanding the pathophysiology in relation to both neural and non-neural dysfunction have been studied. There has been refinement and expansion of the pharmacological and non-pharmacological treatment options for bowel dysfunction in SCI.

Summary

Management of bowel dysfunction in SCI requires a comprehensive and individualized approach, encompassing lifestyle, toileting routine, stimulation, diet, medications, and surgery. Further high-quality research is required to inform best practice.

     

Effect of Preinjury Large Bowel Emptying on the Inhibition of Upper Gastrointestinal Motility After Spinal Cord Injury in Rats

Spinal cord transection (SCT) inhibits gastrointestinal motility in rats. We evaluated the effect of preinjury large bowel emptying on this phenomenon. Male Wistar rats (N = 52) were fasted for 24 or 48 hr with water ad libitum and pretreated with lactose (0.8 g) or saline. Next, laminectomy followed or not by complete SCT between T4 and T5 vertebrae was performed. Phenol red recovery in the stomach and proximal, medial, and distal small intestine was determined 1 day later. In animals submitted to 24 hr fasting + saline, SCT increased gastric recovery by 42.8% decreased medial small intestine recovery by 56.2%, while 48 hr fasting + saline or 24 hr fasting + lactose prevented the inhibition of gastric emptying (GE) in SCT animals. The 48 hr fasting + lactose prevented the inhibition of both GE and gastrointestinal transit. SCT-induced inhibition of upper gastrointestinal motility may involve enhancement of inhibitory reflexes, which can be prevented by large bowel emptying.     

Bladder Neck Dysfunction in Spinal Cord Injury

Spinal cord injury (SCI) impairs the voluntary and autonomic control of storage and emptying functions of the urinary bladder, leading to a marked remodulation of the micturition reflex. Autonomic dysreflexia (AD) is found in SCI patients with a lesion level above T6. The occurrence of AD in SCI patients may also result in bladder neck dysfunction, which is often associated with AD and may cause bladder neck obstruction or inhibit detrusor contractility. Patients with bladder neck dysfunction may present with normal or underactive detrusor contractility, resulting in inefficient bladder emptying and prolonged AD. Using videourodynamic study, bladder neck dysfunction can be clearly demonstrated as a narrow bladder neck associated with a narrow external urethral sphincter and normal detrusor contractility. Medical treatment with α-adrenergic agents is the first-line treatment for patients with bladder neck dysfunction. If medical treatment fails, transurethral incision of the bladder neck is indicated to relieve bladder outlet obstruction and to resume spontaneous detrusor contractility.     

Toxicology Screening in Acute Spinal Cord Injury

The validity of self-reported intoxication at time of spinal cord injury (SCI) was examined for 88 cases at admission to an acute SCI center by comparing self-reports with serum and urine analyses. Serum ethanol greater than 50 mg/dl was the most frequently found substance (observed in 40% of the cases) followed by urine analysis evidence of cocaine (14%), cannabinoids (8%), benzodiazipines (5%), and opiates (4%). Evidence of substances with abuse potential was found in urine for 35% of the sample. While 62% of the sample had either serum ethanol greater than 50 mg/dl or a positive urine analysis, only 42% of the sample reported being under the influence of some substance at the time of SCI. Although the relationship between these two measures was statistically significant, self-report and toxicology analyses were discordant in 34% of the cases. These results suggest that routine drug testing at admission to an SCI center will produce both false-negative and false-positive results if substance presence alone is interpreted as evidence of intoxication.     

Cervical Spinal Cord Injury and Deglutition Disorders

The association of cervical spinal cord injury and swallowing disorders is clinically well recognized. This study was performed to determine the clinical significance and the outcome of deglutition disorders observed in the initial treatment of cervical spinal cord injury in our tertiary care spinal cord injury unit. All patients with cervical spinal cord injury admitted to our facility for initial care between January 1997 and December 2000 were included in our study. Prevalence of dysphagia and frequency of pneumonia were determined. An assessment of deglutition at discharge was performed. Dysphagia was diagnosed in 26 of the 73 patients with cervical spinal cord injury. Tracheostomy and duration of orotracheal intubation are associated with dysphagia. The disorder necessitated dietary restrictions in 18 patients. Six of these patients had to be discharged with a percutaneous enterogastric feeding tube; seven had persistent problems not resulting in dietary restrictions. The incidence of late pneumonia was significantly increased with two associated deaths. Dysphagia is a serious complication associated with prolonged requirement for ventilatory support. Patients have to be monitored closely because the incidence of pneumonia is increased. While the situation improves for most patients, a significant number of patients need a percutaneous enterogastric feeding tube as a permanent solution.     

Long-Term Urologic Evaluation Following Spinal Cord Injury

Spinal cord injury (SCI) has significant long-term urologic consequences that impact quality of life (QOL) and can influence life expectancy. Neurogenic bladder, urinary tract infections, and autonomic dysreflexia are common consequences of SCI. It is essential to conduct a focused patient interview to address these consequences. History should include a basic assessment of the patient and symptomatology as per a validated instrument, as well as a detailed urologic diary. The physical examination should include evaluation of the extent of the neurologic injury as per the American Spinal Association Injury (ASIA) scale, the affected system as well as examination maneuvers done in those without neurologic injury. Investigations should include urodynamic testing and cystoscopy. In managing patients with SCI, pharmaceutical agents and intermittent catheterization are utilized normally in an effort to protect the upper urinary tract, achieve and maintain urinary continence, and optimize lower urinary tract function and quality of life (QOL).     

Management of the Bladder in Spinal Cord Injury Patients

Management of the lower urinary tract in spinal cord injury patients can be very challenging The decision-making process should be based on the individual patient symptoms, which could vary even between patients with a similar level of injury, and an appropriate evaluation. Important factors in the evaluation of patients with neurogenic bladder secondary to spinal cord injury include intravesical detrusor storage pressures, integrity of the outlet, upper extremity function, and the ability to perform clean intermittent catheterization, as well as patient preference when choosing between the various conservative and surgical treatment options available. When used appropriately, treatment of neurogenic bladder can lead to significant improvements in urinary continence, protection of the upper urinary tracts, improved quality of life, and patient independence. This paper reviews the various options available today as well as several potential therapies that may become available in the future.     

胃运动功能对乙醇所致大鼠胃黏膜损伤的影响

目的研究普瑞博斯对乙醇所致胃黏膜损伤的影响,以阐明胃运动功能对胃黏膜的保护作用。方法实验包括两部分,实验1：雄性Wistar大鼠24只,随机分为对照组、普瑞博斯小剂量组和大剂量组,分别给予生理盐水、普瑞博斯0．5mg/kg和普瑞博斯1mg／kg灌胃,然后各组均给予无水乙醇灌胃,检测胃黏膜损伤的面积和深度;实验2：大鼠分组同上,实验前所有大鼠均行幽门结扎术,术后给药及胃黏膜损伤的检测方法刚上。结果于末结扎幽门的大鼠中,大剂量普瑞博斯可显著减少无水乙醇所致的胃黏膜损伤深度和面积,小剂量普瑞博斯也可减少胃黏膜损伤的深度。结扎幽门后,普瑞博斯对无水乙醇所致胃黏膜损伤的保护作用消失。结论普瑞博斯对无水乙醇所致的胃黏膜损伤有保护作用,该作用与普瑞博斯促进胃排空有关,提示胃运动功能对胃黏膜的保护作用。     

Gastric Emptying of Liquids and Postprandial Pancreatobiliary Secretion are Temporarily Impaired During Endotoxemia

The aims of our study were to determinemechanisms by which pancreatobiliary secretion isaltered during endotoxemia. Dogs underwent placement ofduodenal perfusion and aspiration catheters and antralmanometry catheters. Gastric emptying of liquids, antralmotility, output of bile acids and amylase, and serumlevels of enteric hormones were determined afteringestion of a 360-kcal mixed-nutrient liquid meal. Each dog was then given a single dose of E.coli lipopolysaccharide (200 g/kg, intravenously)and the studies repeated for the next three days.Endotoxin slowed gastric emptying of liquids anddecreased amylase output for two days. Bile acid outputwas decreased on postendotoxin day 1. Pancreaticpolypeptide alone was decreased on postendotoxin day 1.We conclude that the decrease in pancreatobiliary output is probably due to decreased nutrient flow intothe duodenum and not due to decreased production ofhormones that influence pancreatobiliary secretion. Thedelayed gastric emptying, decreased pancreatobiliary output, and decreased postprandial levels ofpancreatic polypeptide suggest diminished vagal outputas a possible explanation for the effects of endotoxinon upper gut function.     

Gastric Emptying in Diabetes

Gastric emptying abnormalities are common in diabetic patients but correlate poorly with gastrointestinal symptoms. Poor diabetic control is more likely to lead to gastrointestinal complications of diabetes and the converse is also true. Gastric emptying may be a previously under-recognized contributor to variations in glycaemic control in diabetes. There is evidence for both accelerated and delayed gastric emptying. More rapid gastric emptying would result in higher postprandial glucose levels and, therefore, pharmacological means to delay the rate of gastric emptying may be a new approach to slowing postprandial nutrient absorption and improving diabetic control. Hyperglycaemia reduces the rate of gastric emptying in both Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetic patients. The exact mechanisms responsible for the inhibitory action of hyperglycaemia on gastric emptying are unknown. There is insufficient data on the effect of hypoglycaemia on gastric emptying but one study has reported more rapid gastric emptying.     

US Experience With Bladder Management Following Spinal Cord Injury

This review of management of the neurogenic bladder due to spinal cord injury focuses specifically on the most current literature (2007–2009) regarding therapies offered in the United States. Urodynamic surveillance, indwelling and intermittent catheterization, sphincterotomy, urinary diversion, continent catheterizable stomas, and botulinum toxin usage are all reviewed.     

Impaired Esophageal Emptying in Reflux Disease

Objectives: The symptoms and mncosal damage that occur in gastroesophageal reflux disease (GERD) may he a consequence of either an increased frequency of reflux events or of a prolonged process of esophageal acid clearance. Acid clearance is dependent both upon effective esophageal emptying of luminal fluid and on normal salivary function to titrate residual acid to neutrality. This investigation examined the efficacy of esophageal emptying in a large group of GERD patients. Methods: Barium swallow examinations were done to categorize and quantify esophageal emptying dysfunction in 67 consecutive patients with reflux disease, compared with 85 patient asymptomatic controls. Quantitative fluoroscopic estimates of esophageal residua were compared with scintigraphic quantiflcation in 14 controls and 20 GERD patients. Results: There was progressive impairment of esophageal emptying in the reflux patients without esophagitis compared with the controls, and it was even greater in patients with endoscopically evident esophagitis compared with reflux patients without esophagitis. Good correlation existed hetween the fluoroscopic and scintigraphic assessment of esophageal emptying. Conclusions: These flndings support the hypothesis that impaired esophageal emptying is an important determinant in the development of esophagitis among reflux patients. The dominant site of impaired emptying in the reflux patients was the phrenic ampulla as opposed to the tuhular esophagus, suggesting a pathophysiological contribution of hiatus hernia.     

消化性溃疡患者胃排空功能的初步观察

本文对正常人,十二指肠溃疡,胃溃疡患者共66例,用锝~(99)标记的液体试餐,于服用后5分钟、10分钟分别检测胃的排空率及半排空时间。结果显示,无论是早期相的5分钟和10分钟的液体排空速度还是半排空时间,溃疡病患者组与正常对照相比,均未显示差异。没有排空加速或迟缓的表现。由此推论,在治疗中应用与胃的运动有影响的药物(如多潘立酮,颠茄等),并无实际意义.     

Neuroprotective Effects of Raloxifene on Experimental Spinal Cord Injury in Rats

IntroductionThe aim of this study was to evaluate the possible beneficial effect of raloxifene on cytokine production and ultrastructure of the spinal cord after spinal cord injury (SCI) in an animal model.MethodsForty-eight male, adult Wistar Albino rats were divided into 4 groups for this study: A (only laminectomy), B (trauma; laminectomy + spinal trauma), C (raloxifene group; laminectomy + spinal trauma + raloxifene treated) and D (vehicle group; laminectomy + spinal trauma + vehicle treated). SCI was achieved by compression of the spinal cord horizontally and extradurally for 1 minute with an aneurysm clip (Sugita no: 07-934-11, closing pressure of 1.37-1.72 N). Spinal cords were extirpated at T7–T12 level, and tissue samples of the spinal cord samples were gathered for tumor necrosis factor α (TNF-α)/protein and interleukin (IL)-1β/protein measurements at first and sixth hours. Spinal cords harvested at sixth hour were evaluated for ultrastructural changes.ResultsBoth TNF-α/protein and IL-1β/protein levels in the samples harvested 6 hours after surgery in the group B (62.70 ± 6.67 pg/mg and 11.25 ± 1.37 pg/mg, respectively) were higher than those taken from group A (P = 0.002 and P = 0.041, respectively). Furthermore, TNF-α/protein and IL-1β/protein levels in the samples of animals treated with raloxifene (23.27 ± 5.27 pg/mg and 6.09 ± 0.77 pg/mg, respectively) were significantly lower than those taken from group B (P = 0.002 and P = 0.002, respectively). In the trauma group, electron microscopic examinations revealed deformities inside the cells and severe edema in neuropil. Raloxifene seemed to attenuate these ultrastructural changes at sixth hour after SCI.ConclusionA single dose of 3.0 mg/kg of raloxifene intraperitoneally given 30 minutes after the induction of SCI reduced the production of TNF-α and IL-1β 6 hours after SCI and attenuated ultrastructural changes in a rat model.     

Gastrointestinal Transit after Spinal Cord Injury: Effect of Cisapride

Heartburn, bloating, and abdominal discomfort are common problems in patients with spinal cord injury but, despite its clinical significance, little is known about the gastrointestinal effects of spinal transections. To address the potential gastrointestinal pathophysiology of spinal cord injury, we measured mouth-to-cecum transit time (MCTT) in seven subjects with paraplegia and seven with quadriplegia. Gastric emptying was studied in six subjects with quadriplegia. MCTT was significantly prolonged in patients with quadriplegia, an abnormality corrected by the administration of cisapride. Patients with paraplegia, in contrast to those with quadriplegia, have normal mouth-to-cecum transit time. In addition, patients with quadriplegia had neither a prolonged gastric emptying time nor a change in gastric emptying time, with cisapride. Changes in gastrointestinal transit after spinal cord injury and the improvement of mouth-to-cecum transit time in subjects with quadriplegia, but not in those with paraplegia, may be explained by an imbalance between parasympathetic and sympathetic outflows to the gastrointestinal tract in this group of subjects.     

Gastric Emptying and Intestinal Transit of Various Enteral Feedings Following Severe Burn Injury

Background  

Burn-induced delayed gastric emptying and intestinal transit limits enteral feeding/resuscitation.