Small bowel motility in functional chronic constipation

Abstract  In functional constipation, three pathophysiological subgroups have been identified: slow-transit constipation (STC); normal-transit constipation (NTC) and outlet delay (OD). Extracolonic manifestations, especially disturbed small bowel motility, are well known to occur in STC, but have rarely been studied in NTC and OD. To perform 24-h-ambulatory jejunal manometry in a large prospective series of clinical patients with chronic constipation of all subtypes. A total of 61 consecutive patients, referred to our tertiary gastroenterologic centre for chronic constipation (48 female, 13 male; mean age 57 (range 20–87) years), underwent jejunal 24-h-ambulatory manometry (standardized meal) after a transit-time study (radio-opaque markers), anorectal manometry, defecography and colonoscopy. Computerized and visual analysis by two independent observers was compared with the normal range of manometric variables, defined by data previously obtained in 50 healthy subjects (Gut 1996;38:859). Five patients were excluded from the study because of coexistence of OD and STC. No patient with OD ( n  = 8), but all patients with STC ( n  = 32) and 94% of patients with NTC ( n  = 16) showed small bowel motor abnormalities; both in postprandial response and fasting motility. The abnormal findings ranged from severe disturbances with complete loss of MMC to subtle changes of contraction parameters that could only be assessed by computerized analysis. No significant differences between STC- and NTC-patients were found. Most findings pointed to an underlying enteric neuropathy. Intestinal prolonged-ambulatory manometry adds valuable information to the pathophysiologic understanding of functional chronic constipation of STC- and NTC-type, however there are no distinct manometric features to differentiate between both.     

Motility of the oesophagus and small bowel in adults treated for Hirschsprung’s disease during early childhood

Background Dysmotility of the upper gastrointestinal (GI) tract has been reported in children with Hirschsprung’s disease (HD). In the present study, motility of the oesophagus and the small bowel was studied in adults treated for HD during early childhood to elucidate whether there are alterations in motility of the upper GI tract in this patient group. [Correction added after online publication 15 Sep: The preceding sentence has been rephrased for better clarity.] Methods Ambulatory small bowel manometry with recording sites in duodenum/jejunum was performed in 16 adult patients with surgically treated HD and 17 healthy controls. In addition, oesophageal manometry was performed with station pull‐through technique. Key Results The essential patterns of small bowel motility were recognized in all patients and controls. During fasting, phase III of the migrating motor complex (MMC) was more prominent in patients with HD than in controls when accounting for duration and propagation velocity (P = 0.006). Phase I of the MMC was of shorter duration (P = 0.008), and phase II tended to be of longer duration (P = 0.05) in the patients. During daytime fasting, propagated clustered contractions (PCCs) were more frequent in the patients (P = 0.01). Postprandially, the patients demonstrated a higher contractile frequency (P = 0.02), a shorter duration of contractions (P = 0.008) and more frequent PCCs (P < 0.001). The patients had normal oesophageal motility. Conclusions & Inferences This study demonstrates that adult patients with HD have preserved essential patterns of oesophageal and small bowel motility. However, abnormalities mainly characterized by increased contractile activity of the small bowel during fasting and postprandially are evident. These findings indicate alterations in neuronal control of motility and persistent involvement of the upper GI tract in this disease.     

19Electrogastrography differentiates enteric myopathy from neuropathy in adults with severe motility disorders of the gut

Background:  Chronic intestinal pseudo-obstruction, enteric dysmotility and slow transit constipation are severe motility disorders of the gut that usually are associated with an underlying enteric neuropathy or myopathy. Electrogastrography (EGG) is a non-invasive technique that records gastric myoelectric activity.
Aim of the study:  To determine whether EGG can differentiate enteric myopathy from neuropathy as the primary pathology in patients with severe motility disorders of the gut.
Material and methods:  This is a retrospective analysis of patients with various motility disorders of the gut that underwent full thickness small bowel biopsy. A single bipolar channel measured the EGG. The ability of EGG to differentiate between myopathy and neuropathy was tested by comparing 21 variables from EGG.
Results:  A total of 38 patients, 35 (92%) females, mean age 42 ± 13 years, were analysed. Twenty patients had enteric dysmotility (19 with neuropathy and one with myopathy), 12 had slow transit constipation (10 with neuropathy and two with myopathy), and six had chronic intestinal pseudo-obstruction (three with neuropathy and three with myopathy). Patients with myopathy showed higher percentage of fasting time with DF in bradygastric and tachygastric frequency bands and a higher postprandial DF (Table) than did patients with neuropathic motility disorders.
Conclusions:  Patients with visceral myopathy exhibited more arrhythmia during fasting and a higher DF following the test meal and this indicates that myopathies are associated with more electrical disturbances than neuropathies. EGG may be considered for differentiating between these two disease entities.
 

     

4.

The Relationship Between Clinical Factors and Gastrointestinal Dysmotility in Diabetes Mellitus     

C. H. Kim  F. P. Kennedy  M. Camilleri  A. R. Zinsmeister  D. J. Ballard 《Neurogastroenterology and motility》1991,3(4):268-272

Motility of the stomach and upper intestine was studied in 84 consecutive diabetic patients referred to the Mayo Clinic for evaluation of functional symptoms (nausea, vomiting, or epigastric pain in the absence of structural or mucosal abnormalities). Manometric abnormalities were found in 81 of 84 patients who successfully completed a 3-hour fast and 2-hour postprandial motility evaluation. Antral hypomotility was found in 9 patients, small intestinal dysmotility in 11, and gastric and small-intestinal dysmotilities in 61. The most common abnormalities were the absence of a fed motility pattern after ingestion of the meal and the presence of abnormal intestinal bursts during the fasting period. Clinical factors such as type and duration of diabetes, fasting serum glucose and glycosylated hemoglobin levels, daily dose of insulin therapy, presence of autonomic neuropathy, peripheral neuropathy, retinopathy, and vascular disease were not significantly associated with the severity of gastrointestinal dysmotility. However, there was a significant association between the number of extraintestinal diabetic complications and the severity of gastrointestinal dysmotility (p < 0.05). We conclude that clinical factors, by and large, are not helpful in predicting the severity of gastrointestinal dysmotility among symptomatic diabetic patients.     

5.

Gastric emptying of a non-digestible solid: assessment with simultaneous SmartPill pH and pressure capsule, antroduodenal manometry, gastric emptying scintigraphy     

d.  cassilly  s.  kantor  l. c.  knight †  a. h.  maurer †  r. s.  fisher  j.  semler ‡ & h. p.  parkman 《Neurogastroenterology and motility》2008,20(4):311-319

Abstract  Gastric emptying of digestible solids occurs after trituration of food particles. Non-digestible solids are thought to empty with phase III of the migrating motor complex (MMC). The aim of this study was to determine if a non-digestible capsule given with a meal empties from the stomach with return of the fasting phase III MMC or during the fed pattern with the solid meal. Fifteen normal subjects underwent antroduodenal manometry and ingestion of a radiolabelled meal and SmartPill wireless pH and pressure capsule. In five subjects, emptying of the SmartPill was studied in the fasting period by ingesting the SmartPill with radiolabelled water. The SmartPill emptied from the stomach within 6 h in 14 of 15 subjects. SmartPill pressure recordings showed high amplitude phasic contractions prior to emptying. SmartPill gastric residence time (261 ± 22 min) correlated strongly with time to the first phase III MMC (239 ± 23 min; r  = 0.813; P  < 0.01) and correlated moderately with solid-phase gastric emptying ( r  = 0.606 with T-50% and r  = 0.565 with T-90%). Nine of 14 subjects emptied the capsule with a phase III MMC. In five subjects, the SmartPill emptied with isolated distal antral contractions. In five subjects ingesting only water, SmartPill gastric residence time (92 ± 44 min) correlated with the time to the first phase III MMC (87 ± 30 min; r  = 0.979; P  < 0.01). The non-digestible SmartPill given with a meal primarily empties from the stomach with the return of phase III MMCs occurring after emptying the solid-phase meal. However, in some subjects, the SmartPill emptied with isolated antral contractions, an unappreciated mechanism for emptying of a non-digestible solid.     

6.

Interobserver variability in antroduodenal manometry     

f. l.  connor  p. e.  hyman †  c.  faure ‡  t.  tomomasa §  n.  pehlivanov †  j.  janosky ¶  c.  rudolph  o.  liem †† & c.  di lorenzo †† 《Neurogastroenterology and motility》2009,21(5):500-e3

Abstract  Interobserver variability affects investigations involving assessment of complex visual data, such as histopathology, radiology and motility. This study assessed interobserver variation for interpretation of antroduodenal manometry (ADM), as this has not been previously investigated. Thirty-five ADM recordings from children aged 0.3–18 years were independently evaluated by five experienced paediatric gastroenterologists who were blinded to cases' clinical histories. Intra-class correlation (ICC) was analysed for detection and measurement of phase three of the migrating motor complex (MMC) and Cohen's kappa statistic was calculated between observer pairs for detection of specific motility features and final diagnosis. Observers were unanimous on the differentiation of normal and abnormal motility in 63% of cases. There was excellent interobserver agreement for the number of phase three of the MMC in fasting (ICC = 0.82, P  < 0.0001) and for measurements of phase three of the MMC (ICC = 0.9999, P  < 0.0001). Detection of other normal and abnormal motility patterns varied more. Objective findings such as the presence of phase three of the MMC correlated more closely than findings that involved the integration of several variables, such as final diagnosis. However, these data overall indicate that agreement between expert observers for the distinction of normal and abnormal antroduodenal motility compares favourably with other standard medical assessments.     

7.

Elevated motility-related transmucosal potential difference in the upper small intestine in the irritable bowel syndrome     

m. h.  larsson  ‡  m.  simrén ‡  e. a.  thomas §  j. c.  bornstein §  e.  lindström & h.  sjövall †  ‡ 《Neurogastroenterology and motility》2007,19(10):812-820

The pathophysiology of irritable bowel syndrome (IBS) is complex and incompletely known. Very little has been studied regarding the role of submucous neuronal activity. We therefore measured small intestinal transmural potential difference (PD, reflecting mainly electrogenic chloride secretion), and its linkage with fasting motor activity [migrating motor complex (MMC)] in controls (n = 16) and patients with IBS [n = 23, 14 diarrhoea predominant (d-IBS) and nine constipation predominant (c-IBS)]. Transmural-PD and its relation to MMC phase III was measured by modified multilumen manometry for 3 h in the fasting state using one jejunal and one duodenal infusion line as flowing electrodes. The amplitude and duration of motor phase III was similar in controls and IBS patients, but the propagation speed of phase III was higher in IBS patients. In IBS patients, maximal PD during MMC phase III was significantly elevated in both the duodenum and jejunum (P < 0.05) and the PD decline after phase III was significantly prolonged in the jejunum (P < 0.01). The PD elevation was seen in both duodenum and jejunum in d-IBS patients, but only in the jejunum in the c-IBS patients. On the basis of previous modelling studies, we propose that the enhanced secretion may reflect disturbed enteric network behaviour in some patients with IBS.     

8.

Twenty-four hours blood pressure and heart rate profiles in diabetics with and without autonomic neuropathy.     

M G Felici  V Spallone  M R Maiello  R Gatta  E Civetta  S Frontoni  S Gambardella  G Menzinger 《Functional neurology》1991,6(3):299-304

Previous studies have shown an increased incidence of sudden deaths and lower survival in diabetics with autonomic neuropathy. In hypertensive non diabetic patients a direct correlation has been found between nocturnal blood pressure levels and left ventricular hypertrophy. We have shown in diabetics with autonomic neuropathy a flattening in nocturnal blood pressure reduction and increased 24 hours blood pressure values compared to diabetics without autonomic neuropathy and controls. Our results suggest that abnormalities in 24 hours blood pressure profile might play a role in the increased incidence of cardiovascular morbidity and mortality in diabetics with autonomic neuropathy.     

9.

Visceral hypersensitivity and impaired accommodation in refractory diabetic gastroparesis     

a.  kumar  a.  attaluri  s.  hashmi  k. s.  schulze & s. s. c.  rao 《Neurogastroenterology and motility》2008,20(6):635-642

Abstract  The pathophysiology of persistent gastrointestinal (GI) symptoms in patients with diabetic gastroparesis is poorly understood. Our aim was to evaluate gastric sensation and accommodation to a meal in patients with diabetic gastroparesis and refractory symptoms. We performed intermittent, phasic balloon distensions of the stomach using a gastric barostat device in 18 patients with diabetes and gastroparesis unresponsive to prokinetic therapy and in 13 healthy volunteers. We assessed the biomechanical, sensory and accommodation responses of the stomach, during fasting and after liquid meal. During balloon distension, the sensory thresholds for discomfort were lower ( P  < 0.02) in patients with diabetes than those in controls, in both the fasting and the postprandial states. The accommodation response to a meal was significantly impaired ( P  = 0.01) in patients with diabetes when compared to controls, although fasting gastric tone was similar ( P  = 0.08). Patients with diabetic gastroparesis and refractory GI symptoms demonstrate sensori-motor dysfunction of the stomach, comprising either impaired accommodation, gastric hypersensitivity or both. An objective evaluation of these biomechanical and sensory properties may provide valuable mechanistic insights that could guide therapy.     

10.

Comparison of small‐bowel motility of the human jejunum and ileum     

H. Seidl  F. Gundling  A. Pfeiffer  C. Pehl  W. Schepp  T. Schmidt 《Neurogastroenterology and motility》2012,24(8):e373-e380

Background Knowledge about human cyclic fasting motility (MMC) and the postprandial response is mostly based on manometric findings in the upper small intestine. Hardly any data exist on human ileal motility, as the acquisition of data has been limited by methodological concerns. The aim was to study human jejunal and ileal motility in an optimized manometric setting. Methods Solid‐state 24‐h‐manometry was performed in the jejunum and ileum of healthy individuals, applying a strict protocol for fasting, resting, and the consumption of a standardized meal. Both visual qualitative and validated computerized quantitative contraction and propagation analysis were performed. Key Results MMC occurs in similar frequency in the jejunum and ileum, but it was significantly shorter in the jejunum at night. By many characteristics, ileal motility was less intense and propagative than jejunal: less migrating clustered contractions, and slower propagation velocity and shorter distance in phases II and III, and postprandially – possibly slowing and enhancing nutrient absorption. Prolonged propagated contractions in some individuals were identified as a unique ileal propulsive pattern. Postprandially, an abrupt conversion to a digestive motility pattern occurs simultaneously independent of the region. Conclusions & Inferences We found similar basic phenomena of fasting and postprandial motility in the jejunum and ileum of healthy humans. However, different calibration of propagative and contractile activity and special motor events in the ileum may account for a different physiological role in digestion. Future studies of small‐bowel motility in healthy and diseased subjects focusing on segmental differences of proximal and distal intestine may be rewarded.     

11.

High interdigestive and postprandial motilin levels in patients with the irritable bowel syndrome   总被引：5，自引：0，他引：5  

M. Simrén  E. S. Björnsson  & H. Abrahamsson 《Neurogastroenterology and motility》2005,17(1):51-57

Motilin shows cyclic variation with the different phases of the migrating motor complex (MMC). Altered motilin levels have been found in irritable bowel syndrome (IBS) patients, but in these studies motilin levels were analysed without the knowledge of the phases of MMC. We included 13 healthy controls (HC) and 24 patients with IBS [12 diarrhoea-predominant (IBS-D) and 12 constipation-predominant (IBS-C)]. We performed interdigestive and postprandial antroduodenojejunal manometry and blood samples for analysis of motilin were drawn. Group differences in plasma levels of motilin were analysed during mid-phase II, just before the start of phase III (pre-III), during phase I, immediately before the meal and 30 and 60 min after the 500 kcal mixed meal. Higher motilin levels were observed in IBS vs HC in both the interdigestive and postprandial periods (P < 0.05). No significant differences between IBS-C and IBS-D were observed. The cyclic variation of motilin during MMC and the meal response was similar in IBS and controls. IBS patients, irrespective of the predominant bowel habit, demonstrate higher motilin levels than HCs in all phases of the MMC and also after a meal. These findings may bear some pathophysiological importance in IBS and relate to the gastrointestinal dysmotility often seen in these patients.     

12.

Dysmotility of the small intestine in achalasia     

SCHMIDT  PFEIFFER  HACKELSBERGER  WIDMER  PEHL  & KAESS 《Neurogastroenterology and motility》1999,11(1):11-17

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.     

13.

Swallows, oesophageal and gastric motility in normal subjects and in patients with gastro-oesophageal reflux disease: a 24-h pH-manometric study   总被引：3，自引：0，他引：3  

GROSSI  CICCAGLIONE  TRAVAGLINI  & MARZIO 《Neurogastroenterology and motility》1998,10(2):115-121

Background: the motor aspects underlying gastro-oesophageal reflux disease (GORD) are still not completely clear. Aim: to evaluate the relationship between oesophageal and gastric motility in GORD patients. Patients: twelve patients with grade I–II oesophagitis, mean age 45 yr, and 10 healthy subjects, mean age 42 yr, were studied. Methods: a pH-manometry was performed to analyse oesophageal and gastric motility, swallows and oesophageal pH values for the whole 24-h period, and for the 2-min period before and after each reflux episode. Results: as compared to controls, GORD patients showed in the 24-h period, a greater number of swallows (P < 0.01) and a lower percentage of post deglutitive propagated oesophageal body waves (P < 0.05). The number of migrating motor complexes (MMC) was similar in the two groups, with a lower amplitude of phase III gastric waves in GORD. During MMC reflux episodes were seen only in GORD patients. After refluxes an increase in swallows, simultaneous and secondary oesophageal waves were detected in GORD patients, with a reduction of primary peristalsis. Isolated gastric contractions preceded reflux episodes more frequently in GORD patients than in controls. Conclusions: GORD patients showed an increase in swallows with altered post-deglutitive oesophageal motility and a reduced amplitude of gastric MMC. Moreover small contractions of gastric antrum are present before acid refluxes, suggesting a multifactorial pathogenesis of the disease.     

14.

Visceral perceptions and gastric myoelectrical activity in healthy women and in patients with bulimia nervosa     

K. L. KOCH  S. BINGAMAN  L. TAN  & R. M. STERN 《Neurogastroenterology and motility》1998,10(1):3-10

Bulimia nervosa remains a common eating disorder in young women. Little is known about upper gastrointestinal symptoms or gastric motility in patients with bulimia nervosa. The aim of this study was to measure gastric myoelectrical activity and hunger/satiety and stomach emptiness/fullness before and after a non-nutrient water load and solid-phase gastric emptying in hospitalized patients with bulimia nervosa (n = 12) and in healthy women (n = 13). Gastric myoelectrical activity was measured by means of cutaneous electrodes; visual analogue scales were used to measure perceptions of hunger/satiety and stomach emptiness/fullness. Before and after a standard water load the bulimia patients reported significantly greater stomach fullness and satiety compared with control subjects (P < 0.01). The percentage of gastric myoelectrical power in the normal 3 cpm range was significantly less in bulimics compared with controls. Power in the 1–2 cpm bradygastria range was significantly greater in bulimia patients before and after the water load compared with the control subjects (P < 0.05). Solid-phase gastric emptying studies using radio-isotope-labelled scrambled eggs showed the lag phase was shortened in the bulimic patients (16 ± 4 min vs 31 ± 4 min in controls, P < 0.01), but the percentage of meal emptied at 2 h was similar to control values. In conclusion: bulimia patients had exaggerated perceptions of stomach fullness and satiety in response to water; and abnormal gastric myoelectrical activity and accelerated lag phase of gastric emptying were objective stomach abnormalities detected in hospitalized patients with bulimia nervosa.     

15.

Recto-colonic reflex is impaired in patients with irritable bowel syndrome     

p. p. j.  van der veek  m.  steenvoorden  j.  steens  p. j.  van der schaar  j.  brussee & a. a. m.  masclee 《Neurogastroenterology and motility》2007,19(8):653-659

Motor and sensory dysfunction of the gut are present in a subset of patients with irritable bowel syndrome (IBS). Recent studies have demonstrated the presence of a recto-colonic inhibitory reflex in healthy humans. It is not known whether this reflex exists in IBS. We studied rectal compliance, perception and the recto-colonic reflex by measuring volume responses of the descending colon to rectal distentions by barostat in 26 IBS patients and 13 healthy controls under both fasting and postprandial conditions. In the fasting state, rectal distention inhibited colonic tone and phasic motility to a similar extent in health and IBS. After a meal, rectal distention inhibited colonic tone and phasic motility to a lesser degree (P < 0.05) in IBS than health. Under postprandial but not fasting conditions, rectal distentions of increasing intensity were associated with higher pain scores in IBS than in health. Rectal distention inhibits tonic and phasic motility of the descending colon in healthy controls and in IBS patients. Postprandially this recto-colonic inhibitory reflex is impaired and attenuated in IBS patients compared with controls. These findings point to an altered reflex function in IBS and have implications for pathophysiology and therapy.     

16.

Does the nutrient drink test accurately predict postprandial gastric volume in health and community dyspepsia?   总被引：3，自引：0，他引：3  

J. Gonenne  E. J. Castillo  M. Camilleri  D. Burton  G. M. Thomforde  K. L. Baxter  & A. R. Zinsmeister† 《Neurogastroenterology and motility》2005,17(1):44-50

Abstract  Nutrient drink tests have been proposed as a surrogate for measurement of gastric accommodation. To study the relationship of maximum tolerated volume (MTV) during nutrient drink test and gastric volumes measured by single-photon emission computed tomography (SPECT) in healthy controls and functional dyspepsia (FD) patients. We reviewed data from 85 healthy controls and 35 FD residents of south-eastern Minnesota. All underwent standardized nutrient drink and SPECT studies between August 2000 and June 2003. To test for associations between nutrient drink test and SPECT gastric volumes, we used multiple linear regression and partial regression analyses, assigning age, gender, dyspepsia status and postprandial symptoms as covariates in the model. In the combined group (healthy and FD), MTV was weakly associated with fasting gastric volume ( r  = 0.43, P  = 0.0001) and with volume response to feeding ( r  = 0.25, P  = 0.006). In the FD group, associations were similar (fasting r  = 0.53, P  = 0.001; postmeal r  = 0.32, P  = 0.06). After accounting for covariates, MTV only explained 13 and 3% of variations in fasting and postprandial volumes measured by SPECT. MTV during the nutrient drink test does not accurately reflect gastric volume measurements by SPECT in healthy controls and a sample of people in the community with FD.     

17.

Sigmoid-colonic motility in health and irritable bowel syndrome: a role for 5-hydroxytryptamine   总被引：1，自引：0，他引：1  

l. a.  houghton  w.  atkinson  s.  lockhart †  c.  fell  p. j.  whorwell & b.  keevil † 《Neurogastroenterology and motility》2007,19(9):724-731

Abstract Evidence suggests that sigmoid-colonic motility is increased in patients with irritable bowel syndrome (IBS). 5-Hydroxytryptamine (5-HT) plays a role in the control of motility, but its involvement in the dysmotility seen in IBS remains unclear. To investigate the relationship between platelet depleted plasma 5-HT (PDP 5-HT) concentration and sigmoid-colonic motility in patients with IBS and healthy volunteers. Pre- and postprandial PDP 5-HT concentrations were assessed while recording sigmoid-colonic motility in 35 IBS patients (aged 19-53 years, eight male) and 16 healthy volunteers (aged 18-39 years, six male). Motility was recorded using a five-channel solid-state catheter introduced to a depth of 35 cm into an unprepared bowel. 5-Hydroxytryptamine concentration was measured by reverse-phase HPLC with fluorimetric detection. Irritable bowel syndrome patients had elevated concentrations of PDP 5-HT under fasting (P < 0.004) and fed (P = 0.079) conditions compared with controls. Likewise, they exhibited increased sigmoid-colonic motility under fasting (activity index: P < 0.02) and fed (P < 0.05) conditions compared with controls. Platelet depleted plasma 5-HT concentration positively correlated with colonic activity index under both fasting (r = 0.402; P = 0.003) and fed (r = 0.439; P = 0.001) conditions. These data show a possible relationship between endogenous concentrations of 5-HT and sigmoid-colonic motility recorded in both IBS and healthy subjects.     

18.

Comparison of electrophysiologic and autonomic tests in sensory diabetic neuropathy     

Dr. Mikihiro Kihara  Manami Mitsui  Shogo Nishikawa  Kazuhiro Nishimoto  Mituo Takahashi 《Clinical autonomic research》1998,8(4):213-220

We examined autonomic function in 46 patients with symmetric sensory non-insulin dependent diabetic neuropathy without autonomic symptoms and 31 age-matched control patients using the composite autonomic scoring scale (CASS) and electrophysiologic examination. The patients were divided into three groups by subjective severity of pain or numbness; 17 had slight pain or numbness, 15 had mild pain or numbness, and 14 had moderate pain or numbness. The patients in the moderate group had the following: a mild reduction in systolic and mean blood pressure (BP) within 1 minute of head-up tilt and a partial recovery after 5 minutes; an excessive fall in early phase II (IIe), an absence of late phase II (III) and reduced phase IV beat-to-beat BP responses to Valsalva maneuver (VM); a poor heart rate response to deep breathing; a reduced quantitative sudomotor axon reflex test (QSART) response in distal leg and foot; the highest CASS among the 3 groups; and reduced conduction velocity and amplitude in post-tibial nerve and sural nerve. The mild group had a mild reduction in BP during phase IIe and an absent phase III but normal phase IV overshoot during VM; a reduced QSART in the foot; a CASS between the moderate and slight groups; and reduced conduction velocity and amplitude in post-tibial nerve and reduced amplitude in sural nerve. The slight pain group had no abnormalities except for mild cardiovagal dysfunction. CASS gathered from all cases had a significant correlation with amplitude of sural nerve. These results suggest that the patients with symmetric sensory diabetic neuropathy may also have autonomic dysfunction, although they did not have any obvious autonomic symptoms, and that abnormalities in autonomic function parallel changes in somatic function in peripheral nerve. The CASS may be a sensitive tool, similar to the neurophysiologic test, for assessing diabetic neuropathy.     

19.

Effects of glucagon-like peptide-1 and feeding on gastric volumes in diabetes mellitus with cardio-vagal dysfunction     

S. Delgado-Aros  A. Vella  M. Camilleri  P. A. Low†  D. D. Burton  G. M. Thomforde  & D. Stephens 《Neurogastroenterology and motility》2003,15(4):435-443

Glucagon-like peptide-1 (GLP-1) increases gastric volume in humans possibly through the vagus nerve. Gastric volume response to feeding is preserved after vagal denervation in animals. We evaluated gastric volume responses to GLP-1 and placebo in seven diabetic patients with vagal neuropathy in a crossover study. We also compared gastric volume response to feeding in diabetes with that in healthy controls. We measured gastric volume using SPECT imaging. Data are median (interquartile range). In diabetic patients, GLP-1 did not increase gastric volume during fasting [5 mL (-3; 30)] relative to placebo [4 mL (-14; 50) P = 0.5], or postprandially [Delta postprandial minus fasting volume 469 mL (383; 563) with GLP-1 and 452 mL (400; 493) with placebo P = 0.3]. Change in gastric volume over fasting in diabetic patients on placebo was comparable to that of healthy controls [452 mL (400; 493)], P = 0.5. In contrast to effects in health, GLP-1 did not increase gastric volume in diabetics with vagal neuropathy, suggesting GLP-1's effects on stomach volume are vagally mediated. Normal gastric volume response to feeding in diabetics with vagal neuropathy suggests that other mechanisms compensate for vagal denervation.     

20.

Comparative analysis of phase III migrating motor complexes in stomach and small bowel using wireless motility capsule and antroduodenal manometry     

Brun R  Michalek W  Surjanhata BC  Parkman HP  Semler JR  Kuo B 《Neurogastroenterology and motility》2012,24(4):332-e165

Background Assessment of phase III MMC is often not performed due to the invasive nature of antroduodenal manometry used to detect it. The aim of the study was to evaluate the ability of wireless motility capsule (WMC) to detect phase III MMC and correlate it with the simultaneous measurements by antroduodenal manometry (ADM). Methods Eighteen patients underwent simultaneous ADM and WMC. MMCs were identified first on ADM and then correlated with WMC events occurring simultaneously. Frequency of contractions per min, AUC, MI, and criteria for amplitude thresholds of contractions representing MCCs on WMC tracings were defined. Key Results In 18 patients, a total of 29 MMCs were recorded by ADM. WMC detected 86% of MMC events measured by ADM. Hundred percent (10/10) of MMCs in stomach were detected by WMC, whereas 79% (15/19) of MMCs were detected in SB. The sensitivity and specificity of WMC high amplitude contractions to represent phase III MMC were 90% and 71.8% in the stomach; 73.7% and 84.7% in SB, respectively, and negative predictive value was 99.9% in both regions. Conclusions & Inferences Wireless motility capsule was able to detect the phase III MMCs as the high amplitude contractions with good fidelity. WMC does not detect the propagation of MMC. Using the pressure thresholds, WMC can detect high amplitude contraction representing phase III MMC with favorable sensitivity/specificity profile and 99.9% negative predictive value. This observation may have clinical significance, as the absence of high amplitude contractions recorded by WMC during fasting state suggests absence of MMCs.     

The Relationship Between Clinical Factors and Gastrointestinal Dysmotility in Diabetes Mellitus

Motility of the stomach and upper intestine was studied in 84 consecutive diabetic patients referred to the Mayo Clinic for evaluation of functional symptoms (nausea, vomiting, or epigastric pain in the absence of structural or mucosal abnormalities). Manometric abnormalities were found in 81 of 84 patients who successfully completed a 3-hour fast and 2-hour postprandial motility evaluation. Antral hypomotility was found in 9 patients, small intestinal dysmotility in 11, and gastric and small-intestinal dysmotilities in 61. The most common abnormalities were the absence of a fed motility pattern after ingestion of the meal and the presence of abnormal intestinal bursts during the fasting period. Clinical factors such as type and duration of diabetes, fasting serum glucose and glycosylated hemoglobin levels, daily dose of insulin therapy, presence of autonomic neuropathy, peripheral neuropathy, retinopathy, and vascular disease were not significantly associated with the severity of gastrointestinal dysmotility. However, there was a significant association between the number of extraintestinal diabetic complications and the severity of gastrointestinal dysmotility (p < 0.05). We conclude that clinical factors, by and large, are not helpful in predicting the severity of gastrointestinal dysmotility among symptomatic diabetic patients.     

Gastric emptying of a non-digestible solid: assessment with simultaneous SmartPill pH and pressure capsule, antroduodenal manometry, gastric emptying scintigraphy

Abstract  Gastric emptying of digestible solids occurs after trituration of food particles. Non-digestible solids are thought to empty with phase III of the migrating motor complex (MMC). The aim of this study was to determine if a non-digestible capsule given with a meal empties from the stomach with return of the fasting phase III MMC or during the fed pattern with the solid meal. Fifteen normal subjects underwent antroduodenal manometry and ingestion of a radiolabelled meal and SmartPill wireless pH and pressure capsule. In five subjects, emptying of the SmartPill was studied in the fasting period by ingesting the SmartPill with radiolabelled water. The SmartPill emptied from the stomach within 6 h in 14 of 15 subjects. SmartPill pressure recordings showed high amplitude phasic contractions prior to emptying. SmartPill gastric residence time (261 ± 22 min) correlated strongly with time to the first phase III MMC (239 ± 23 min; r  = 0.813; P  < 0.01) and correlated moderately with solid-phase gastric emptying ( r  = 0.606 with T-50% and r  = 0.565 with T-90%). Nine of 14 subjects emptied the capsule with a phase III MMC. In five subjects, the SmartPill emptied with isolated distal antral contractions. In five subjects ingesting only water, SmartPill gastric residence time (92 ± 44 min) correlated with the time to the first phase III MMC (87 ± 30 min; r  = 0.979; P  < 0.01). The non-digestible SmartPill given with a meal primarily empties from the stomach with the return of phase III MMCs occurring after emptying the solid-phase meal. However, in some subjects, the SmartPill emptied with isolated antral contractions, an unappreciated mechanism for emptying of a non-digestible solid.     

Interobserver variability in antroduodenal manometry

Abstract  Interobserver variability affects investigations involving assessment of complex visual data, such as histopathology, radiology and motility. This study assessed interobserver variation for interpretation of antroduodenal manometry (ADM), as this has not been previously investigated. Thirty-five ADM recordings from children aged 0.3–18 years were independently evaluated by five experienced paediatric gastroenterologists who were blinded to cases' clinical histories. Intra-class correlation (ICC) was analysed for detection and measurement of phase three of the migrating motor complex (MMC) and Cohen's kappa statistic was calculated between observer pairs for detection of specific motility features and final diagnosis. Observers were unanimous on the differentiation of normal and abnormal motility in 63% of cases. There was excellent interobserver agreement for the number of phase three of the MMC in fasting (ICC = 0.82, P  < 0.0001) and for measurements of phase three of the MMC (ICC = 0.9999, P  < 0.0001). Detection of other normal and abnormal motility patterns varied more. Objective findings such as the presence of phase three of the MMC correlated more closely than findings that involved the integration of several variables, such as final diagnosis. However, these data overall indicate that agreement between expert observers for the distinction of normal and abnormal antroduodenal motility compares favourably with other standard medical assessments.     

Elevated motility-related transmucosal potential difference in the upper small intestine in the irritable bowel syndrome

The pathophysiology of irritable bowel syndrome (IBS) is complex and incompletely known. Very little has been studied regarding the role of submucous neuronal activity. We therefore measured small intestinal transmural potential difference (PD, reflecting mainly electrogenic chloride secretion), and its linkage with fasting motor activity [migrating motor complex (MMC)] in controls (n = 16) and patients with IBS [n = 23, 14 diarrhoea predominant (d-IBS) and nine constipation predominant (c-IBS)]. Transmural-PD and its relation to MMC phase III was measured by modified multilumen manometry for 3 h in the fasting state using one jejunal and one duodenal infusion line as flowing electrodes. The amplitude and duration of motor phase III was similar in controls and IBS patients, but the propagation speed of phase III was higher in IBS patients. In IBS patients, maximal PD during MMC phase III was significantly elevated in both the duodenum and jejunum (P < 0.05) and the PD decline after phase III was significantly prolonged in the jejunum (P < 0.01). The PD elevation was seen in both duodenum and jejunum in d-IBS patients, but only in the jejunum in the c-IBS patients. On the basis of previous modelling studies, we propose that the enhanced secretion may reflect disturbed enteric network behaviour in some patients with IBS.     

Twenty-four hours blood pressure and heart rate profiles in diabetics with and without autonomic neuropathy.

Previous studies have shown an increased incidence of sudden deaths and lower survival in diabetics with autonomic neuropathy. In hypertensive non diabetic patients a direct correlation has been found between nocturnal blood pressure levels and left ventricular hypertrophy. We have shown in diabetics with autonomic neuropathy a flattening in nocturnal blood pressure reduction and increased 24 hours blood pressure values compared to diabetics without autonomic neuropathy and controls. Our results suggest that abnormalities in 24 hours blood pressure profile might play a role in the increased incidence of cardiovascular morbidity and mortality in diabetics with autonomic neuropathy.     

Visceral hypersensitivity and impaired accommodation in refractory diabetic gastroparesis

Abstract  The pathophysiology of persistent gastrointestinal (GI) symptoms in patients with diabetic gastroparesis is poorly understood. Our aim was to evaluate gastric sensation and accommodation to a meal in patients with diabetic gastroparesis and refractory symptoms. We performed intermittent, phasic balloon distensions of the stomach using a gastric barostat device in 18 patients with diabetes and gastroparesis unresponsive to prokinetic therapy and in 13 healthy volunteers. We assessed the biomechanical, sensory and accommodation responses of the stomach, during fasting and after liquid meal. During balloon distension, the sensory thresholds for discomfort were lower ( P  < 0.02) in patients with diabetes than those in controls, in both the fasting and the postprandial states. The accommodation response to a meal was significantly impaired ( P  = 0.01) in patients with diabetes when compared to controls, although fasting gastric tone was similar ( P  = 0.08). Patients with diabetic gastroparesis and refractory GI symptoms demonstrate sensori-motor dysfunction of the stomach, comprising either impaired accommodation, gastric hypersensitivity or both. An objective evaluation of these biomechanical and sensory properties may provide valuable mechanistic insights that could guide therapy.     

Comparison of small‐bowel motility of the human jejunum and ileum

Background Knowledge about human cyclic fasting motility (MMC) and the postprandial response is mostly based on manometric findings in the upper small intestine. Hardly any data exist on human ileal motility, as the acquisition of data has been limited by methodological concerns. The aim was to study human jejunal and ileal motility in an optimized manometric setting. Methods Solid‐state 24‐h‐manometry was performed in the jejunum and ileum of healthy individuals, applying a strict protocol for fasting, resting, and the consumption of a standardized meal. Both visual qualitative and validated computerized quantitative contraction and propagation analysis were performed. Key Results MMC occurs in similar frequency in the jejunum and ileum, but it was significantly shorter in the jejunum at night. By many characteristics, ileal motility was less intense and propagative than jejunal: less migrating clustered contractions, and slower propagation velocity and shorter distance in phases II and III, and postprandially – possibly slowing and enhancing nutrient absorption. Prolonged propagated contractions in some individuals were identified as a unique ileal propulsive pattern. Postprandially, an abrupt conversion to a digestive motility pattern occurs simultaneously independent of the region. Conclusions & Inferences We found similar basic phenomena of fasting and postprandial motility in the jejunum and ileum of healthy humans. However, different calibration of propagative and contractile activity and special motor events in the ileum may account for a different physiological role in digestion. Future studies of small‐bowel motility in healthy and diseased subjects focusing on segmental differences of proximal and distal intestine may be rewarded.     

High interdigestive and postprandial motilin levels in patients with the irritable bowel syndrome

Motilin shows cyclic variation with the different phases of the migrating motor complex (MMC). Altered motilin levels have been found in irritable bowel syndrome (IBS) patients, but in these studies motilin levels were analysed without the knowledge of the phases of MMC. We included 13 healthy controls (HC) and 24 patients with IBS [12 diarrhoea-predominant (IBS-D) and 12 constipation-predominant (IBS-C)]. We performed interdigestive and postprandial antroduodenojejunal manometry and blood samples for analysis of motilin were drawn. Group differences in plasma levels of motilin were analysed during mid-phase II, just before the start of phase III (pre-III), during phase I, immediately before the meal and 30 and 60 min after the 500 kcal mixed meal. Higher motilin levels were observed in IBS vs HC in both the interdigestive and postprandial periods (P < 0.05). No significant differences between IBS-C and IBS-D were observed. The cyclic variation of motilin during MMC and the meal response was similar in IBS and controls. IBS patients, irrespective of the predominant bowel habit, demonstrate higher motilin levels than HCs in all phases of the MMC and also after a meal. These findings may bear some pathophysiological importance in IBS and relate to the gastrointestinal dysmotility often seen in these patients.     

Dysmotility of the small intestine in achalasia

During recent years there has been increasing evidence for extraoesophageal dysfunction in achalasia. The aim was to investigate whether motility of the small intestine is abnormal in achalasia. Thirteen patients (eight men, five women) aged 52 (33-85) years were studied. They had all previously undergone treatment with pneumatic balloon dilatation and were free of dysphagia when examined. Ambulatory 24-h motility was recorded in the upper jejunum under standardized caloric intake with a digital datalogger and catheter-mounted pressure transducers located beyond the ligament of Treitz. Visual analysis was performed by two observers and data underwent quantitative analysis of phasic contractile events using a computer program. Normal values were obtained from 50 healthy controls. In the fasting state, a complete loss of cyclic MMC activity (n = 2), an abnormally prolonged phase II (n = 2) and disturbances in the aboral migration of phase III (n = 5) were observed. Postprandial motor response was absent (n = 2) or frequently showed a contraction frequency below the normal range (n = 5). Further abnormalities consisted in hypomotility during phase II (n = 3) and in a reduced frequency of migrating clustered contractions in the fasting (n = 2) or postprandial state (n = 2). In addition, motor events not present in any healthy subject, giant migrating contractions (n = 5), retrograde clustered contractions (n = 6) and repetitive retrograde contractions (n = 3) were identified. Each patient exhibited findings out of the range of normal. Dysmotility of the proximal small intestine is present in achalasia.     

Swallows, oesophageal and gastric motility in normal subjects and in patients with gastro-oesophageal reflux disease: a 24-h pH-manometric study

Background: the motor aspects underlying gastro-oesophageal reflux disease (GORD) are still not completely clear. Aim: to evaluate the relationship between oesophageal and gastric motility in GORD patients. Patients: twelve patients with grade I–II oesophagitis, mean age 45 yr, and 10 healthy subjects, mean age 42 yr, were studied. Methods: a pH-manometry was performed to analyse oesophageal and gastric motility, swallows and oesophageal pH values for the whole 24-h period, and for the 2-min period before and after each reflux episode. Results: as compared to controls, GORD patients showed in the 24-h period, a greater number of swallows (P < 0.01) and a lower percentage of post deglutitive propagated oesophageal body waves (P < 0.05). The number of migrating motor complexes (MMC) was similar in the two groups, with a lower amplitude of phase III gastric waves in GORD. During MMC reflux episodes were seen only in GORD patients. After refluxes an increase in swallows, simultaneous and secondary oesophageal waves were detected in GORD patients, with a reduction of primary peristalsis. Isolated gastric contractions preceded reflux episodes more frequently in GORD patients than in controls. Conclusions: GORD patients showed an increase in swallows with altered post-deglutitive oesophageal motility and a reduced amplitude of gastric MMC. Moreover small contractions of gastric antrum are present before acid refluxes, suggesting a multifactorial pathogenesis of the disease.     

Visceral perceptions and gastric myoelectrical activity in healthy women and in patients with bulimia nervosa

Bulimia nervosa remains a common eating disorder in young women. Little is known about upper gastrointestinal symptoms or gastric motility in patients with bulimia nervosa. The aim of this study was to measure gastric myoelectrical activity and hunger/satiety and stomach emptiness/fullness before and after a non-nutrient water load and solid-phase gastric emptying in hospitalized patients with bulimia nervosa (n = 12) and in healthy women (n = 13). Gastric myoelectrical activity was measured by means of cutaneous electrodes; visual analogue scales were used to measure perceptions of hunger/satiety and stomach emptiness/fullness. Before and after a standard water load the bulimia patients reported significantly greater stomach fullness and satiety compared with control subjects (P < 0.01). The percentage of gastric myoelectrical power in the normal 3 cpm range was significantly less in bulimics compared with controls. Power in the 1–2 cpm bradygastria range was significantly greater in bulimia patients before and after the water load compared with the control subjects (P < 0.05). Solid-phase gastric emptying studies using radio-isotope-labelled scrambled eggs showed the lag phase was shortened in the bulimic patients (16 ± 4 min vs 31 ± 4 min in controls, P < 0.01), but the percentage of meal emptied at 2 h was similar to control values. In conclusion: bulimia patients had exaggerated perceptions of stomach fullness and satiety in response to water; and abnormal gastric myoelectrical activity and accelerated lag phase of gastric emptying were objective stomach abnormalities detected in hospitalized patients with bulimia nervosa.     

Recto-colonic reflex is impaired in patients with irritable bowel syndrome

Motor and sensory dysfunction of the gut are present in a subset of patients with irritable bowel syndrome (IBS). Recent studies have demonstrated the presence of a recto-colonic inhibitory reflex in healthy humans. It is not known whether this reflex exists in IBS. We studied rectal compliance, perception and the recto-colonic reflex by measuring volume responses of the descending colon to rectal distentions by barostat in 26 IBS patients and 13 healthy controls under both fasting and postprandial conditions. In the fasting state, rectal distention inhibited colonic tone and phasic motility to a similar extent in health and IBS. After a meal, rectal distention inhibited colonic tone and phasic motility to a lesser degree (P < 0.05) in IBS than health. Under postprandial but not fasting conditions, rectal distentions of increasing intensity were associated with higher pain scores in IBS than in health. Rectal distention inhibits tonic and phasic motility of the descending colon in healthy controls and in IBS patients. Postprandially this recto-colonic inhibitory reflex is impaired and attenuated in IBS patients compared with controls. These findings point to an altered reflex function in IBS and have implications for pathophysiology and therapy.     

Does the nutrient drink test accurately predict postprandial gastric volume in health and community dyspepsia?

Abstract  Nutrient drink tests have been proposed as a surrogate for measurement of gastric accommodation. To study the relationship of maximum tolerated volume (MTV) during nutrient drink test and gastric volumes measured by single-photon emission computed tomography (SPECT) in healthy controls and functional dyspepsia (FD) patients. We reviewed data from 85 healthy controls and 35 FD residents of south-eastern Minnesota. All underwent standardized nutrient drink and SPECT studies between August 2000 and June 2003. To test for associations between nutrient drink test and SPECT gastric volumes, we used multiple linear regression and partial regression analyses, assigning age, gender, dyspepsia status and postprandial symptoms as covariates in the model. In the combined group (healthy and FD), MTV was weakly associated with fasting gastric volume ( r  = 0.43, P  = 0.0001) and with volume response to feeding ( r  = 0.25, P  = 0.006). In the FD group, associations were similar (fasting r  = 0.53, P  = 0.001; postmeal r  = 0.32, P  = 0.06). After accounting for covariates, MTV only explained 13 and 3% of variations in fasting and postprandial volumes measured by SPECT. MTV during the nutrient drink test does not accurately reflect gastric volume measurements by SPECT in healthy controls and a sample of people in the community with FD.     

Sigmoid-colonic motility in health and irritable bowel syndrome: a role for 5-hydroxytryptamine

Abstract Evidence suggests that sigmoid-colonic motility is increased in patients with irritable bowel syndrome (IBS). 5-Hydroxytryptamine (5-HT) plays a role in the control of motility, but its involvement in the dysmotility seen in IBS remains unclear. To investigate the relationship between platelet depleted plasma 5-HT (PDP 5-HT) concentration and sigmoid-colonic motility in patients with IBS and healthy volunteers. Pre- and postprandial PDP 5-HT concentrations were assessed while recording sigmoid-colonic motility in 35 IBS patients (aged 19-53 years, eight male) and 16 healthy volunteers (aged 18-39 years, six male). Motility was recorded using a five-channel solid-state catheter introduced to a depth of 35 cm into an unprepared bowel. 5-Hydroxytryptamine concentration was measured by reverse-phase HPLC with fluorimetric detection. Irritable bowel syndrome patients had elevated concentrations of PDP 5-HT under fasting (P < 0.004) and fed (P = 0.079) conditions compared with controls. Likewise, they exhibited increased sigmoid-colonic motility under fasting (activity index: P < 0.02) and fed (P < 0.05) conditions compared with controls. Platelet depleted plasma 5-HT concentration positively correlated with colonic activity index under both fasting (r = 0.402; P = 0.003) and fed (r = 0.439; P = 0.001) conditions. These data show a possible relationship between endogenous concentrations of 5-HT and sigmoid-colonic motility recorded in both IBS and healthy subjects.     

Comparison of electrophysiologic and autonomic tests in sensory diabetic neuropathy

We examined autonomic function in 46 patients with symmetric sensory non-insulin dependent diabetic neuropathy without autonomic symptoms and 31 age-matched control patients using the composite autonomic scoring scale (CASS) and electrophysiologic examination. The patients were divided into three groups by subjective severity of pain or numbness; 17 had slight pain or numbness, 15 had mild pain or numbness, and 14 had moderate pain or numbness. The patients in the moderate group had the following: a mild reduction in systolic and mean blood pressure (BP) within 1 minute of head-up tilt and a partial recovery after 5 minutes; an excessive fall in early phase II (IIe), an absence of late phase II (III) and reduced phase IV beat-to-beat BP responses to Valsalva maneuver (VM); a poor heart rate response to deep breathing; a reduced quantitative sudomotor axon reflex test (QSART) response in distal leg and foot; the highest CASS among the 3 groups; and reduced conduction velocity and amplitude in post-tibial nerve and sural nerve. The mild group had a mild reduction in BP during phase IIe and an absent phase III but normal phase IV overshoot during VM; a reduced QSART in the foot; a CASS between the moderate and slight groups; and reduced conduction velocity and amplitude in post-tibial nerve and reduced amplitude in sural nerve. The slight pain group had no abnormalities except for mild cardiovagal dysfunction. CASS gathered from all cases had a significant correlation with amplitude of sural nerve. These results suggest that the patients with symmetric sensory diabetic neuropathy may also have autonomic dysfunction, although they did not have any obvious autonomic symptoms, and that abnormalities in autonomic function parallel changes in somatic function in peripheral nerve. The CASS may be a sensitive tool, similar to the neurophysiologic test, for assessing diabetic neuropathy.     

Effects of glucagon-like peptide-1 and feeding on gastric volumes in diabetes mellitus with cardio-vagal dysfunction

Glucagon-like peptide-1 (GLP-1) increases gastric volume in humans possibly through the vagus nerve. Gastric volume response to feeding is preserved after vagal denervation in animals. We evaluated gastric volume responses to GLP-1 and placebo in seven diabetic patients with vagal neuropathy in a crossover study. We also compared gastric volume response to feeding in diabetes with that in healthy controls. We measured gastric volume using SPECT imaging. Data are median (interquartile range). In diabetic patients, GLP-1 did not increase gastric volume during fasting [5 mL (-3; 30)] relative to placebo [4 mL (-14; 50) P = 0.5], or postprandially [Delta postprandial minus fasting volume 469 mL (383; 563) with GLP-1 and 452 mL (400; 493) with placebo P = 0.3]. Change in gastric volume over fasting in diabetic patients on placebo was comparable to that of healthy controls [452 mL (400; 493)], P = 0.5. In contrast to effects in health, GLP-1 did not increase gastric volume in diabetics with vagal neuropathy, suggesting GLP-1's effects on stomach volume are vagally mediated. Normal gastric volume response to feeding in diabetics with vagal neuropathy suggests that other mechanisms compensate for vagal denervation.     

Comparative analysis of phase III migrating motor complexes in stomach and small bowel using wireless motility capsule and antroduodenal manometry

Background Assessment of phase III MMC is often not performed due to the invasive nature of antroduodenal manometry used to detect it. The aim of the study was to evaluate the ability of wireless motility capsule (WMC) to detect phase III MMC and correlate it with the simultaneous measurements by antroduodenal manometry (ADM). Methods Eighteen patients underwent simultaneous ADM and WMC. MMCs were identified first on ADM and then correlated with WMC events occurring simultaneously. Frequency of contractions per min, AUC, MI, and criteria for amplitude thresholds of contractions representing MCCs on WMC tracings were defined. Key Results In 18 patients, a total of 29 MMCs were recorded by ADM. WMC detected 86% of MMC events measured by ADM. Hundred percent (10/10) of MMCs in stomach were detected by WMC, whereas 79% (15/19) of MMCs were detected in SB. The sensitivity and specificity of WMC high amplitude contractions to represent phase III MMC were 90% and 71.8% in the stomach; 73.7% and 84.7% in SB, respectively, and negative predictive value was 99.9% in both regions. Conclusions & Inferences Wireless motility capsule was able to detect the phase III MMCs as the high amplitude contractions with good fidelity. WMC does not detect the propagation of MMC. Using the pressure thresholds, WMC can detect high amplitude contraction representing phase III MMC with favorable sensitivity/specificity profile and 99.9% negative predictive value. This observation may have clinical significance, as the absence of high amplitude contractions recorded by WMC during fasting state suggests absence of MMCs.