Relationship among gastric motility, autonomic activity, and portal hemodynamics in patients with liver cirrhosis

BACKGROUND AND AIMS: We examined the effects of the autonomic nervous function and the volume of portal blood flow to clarify the mechanism of the abnormal gastric motility in patients with liver cirrhosis. METHODS: Heart rate variability, electrogastrogram (EGG), and volume of portal blood flow were measured before and after a meal in 27 patients with liver cirrhosis (LC group) and in 20 normal subjects (N group). Autonomic nervous function was evaluated by using spectral analysis of heart rate variability. We used the cine phase-contrast (PC) method, using magnetic resonance imaging (MRI) to measure the portal flow, while the peak frequency and spectral power of the EGG were measured at pre- and postprandial change. RESULTS: The ratio of low frequency power to high frequency power (LF/HF) was significantly higher, and the HF power was significantly lower in the LC group than in the N group both before and after a meal. In both groups, the electrogastrographic peak power ratio before and after a meal showed a positive correlation with the HF ratio, and an inverse correlation with the LF/HF ratio. In addition, portal blood flow volume was significantly decreased in the LC group than in the N group. However, the increased rate of portal blood flow after a meal correlated positively with the increased rate of electrogastrographic peak power. Moreover, gastric motility was positively correlated with esophageal varices and coma scale with the use of multivariate analysis. CONCLUSIONS: Parasympathetic hypofunction, sympathetic hyperfunction and portal hemodynamics were closely related with gastric motility in cirrhotic patients. In addition, gastric motility was decreased, at least in part, by the ingestion of food in cirrhotic patients because of abnormalities in autonomic functions and portal blood flow following a meal.     

肝硬化食管胃静脉曲张破裂出血的防治

食管胃静脉曲张破裂出血是肝硬化患者的严重并发症,病死率高,是最常见的消化系统急症之一。近年来,随着研究的深入,食管胃静脉曲张破裂出血的预防和治疗方法都有了一些新的进展,本文对此进行综述。     

肝硬化患者食管胃底静脉曲张破裂早期再出血的危险因素分析

目的探讨影响食管胃底静脉曲张破裂出血(EGVB)患者再出血的危险因素。方法收集宁夏医科大学2006年1月-2009年12月收住入院的432例肝硬化患者,初次治疗后出血停止的325例为对照组(即出血停止组),再出血的107例为研究组(即再出血组)。分析2组患者的临床和相关检查资料。两组间计量资料的比较采用t检验,计数资料的比较采用卡方检验,并进行多个样本率间的多重比较。应用单因素非条件Logistic回归模型分析出血的影响因素。结果性别、吸烟、血红蛋白、白细胞、ALT、AST、脾脏厚度两组患者中差异有统计学意义(P0.05)。单因素非条件Logistic回归分析中性粒细胞相对值(OR=0.976,P=0.034)、白细胞计数(OR=1.173,P=0.007)、门静脉宽度(OR=7.530,P=0.001)和血红蛋白(OR=1.015,P=0.013)与出血具有相关性。结论白细胞、中性粒细胞、血红蛋白、门静脉为肝硬化食管胃底静脉曲张破裂早期再出血的危险因素。     

肝硬化患者血浆胆囊收缩素及胃动素对胃排空的影响

目的本研究旨在探讨肝硬化患者胃排空功能,并探讨其胃排空作用与空腹血浆胆囊收缩素、胃动素的关系,进而为预防和治疗肝硬化提供参考。方法 将30例肝硬化患者作为试验组,30例健康志愿者作为对照组,采用^13C-辛酸呼气试验法测定肝硬化患者以及对照组的胃固体半排空时间（GET1／2）,同时用放射免疫技术测定患者及对照组的空腹血浆胆囊收缩素（CCK）及胃动素（MTL）水平。结果与健康志愿者组相比,肝硬化患者组GET1／2明显延迟（P〈0．05）;空腹血浆CCIK及MTL水平明显升高,组间差异有统计学意义（P〈0．05）;患者GET1／2与空腹血浆CCK及MTL水平各自呈正相关。结论肝硬化患者胃排空延迟可能与血浆CCK及MTL水平的异常增高相关。推测肝硬化时血浆CCK及MTL水平均明显增高,由此引发胃排空延迟,最终导致营养不良,进而加重患者病情。     

Role of gastric sensorimotor dysfunction in gastrointestinal symptoms and energy intake in liver cirrhosis

Objective. Altered gastric sensorimotor function is related to the symptomatology in several gastrointestinal diseases. Gastrointestinal symptoms in patients with cirrhosis may result in low energy intake contributing to malnutrition and increased morbidity. The aim of this study was to investigate gastric accommodation to a meal and sensitivity to gastric distension with reference to energy intake, nutritional status and gastrointestinal symptoms in liver cirrhosis. Material and methods. Sixteen patients with cirrhosis and 15 healthy controls underwent a gastric barostat study to assess gastric accommodation to a meal and sensory thresholds for first perception and discomfort. The patients also underwent a slow caloric satiety drinking test. Food intake and nutritional status were also evaluated and gastrointestinal symptoms were assessed by means of a questionnaire. Results. Compared with controls, patients with cirrhosis had enhanced gastric accommodation (p<0.05) but lower daily energy intake (p<0.05). Patients with versus those without compromised nutritional status had enhanced gastric accommodation (p<0.05). Gastric accommodation was correlated to daily energy intake in controls (r=0.67, p<0.05) but not in cirrhotic patients (p>0.4). The end-point of the satiety test was inversely related to gastric volumes in cirrhotic patients. Mean post-meal balloon volumes were positively correlated to the Model for End Stage Liver Disease (MELD) score (r=0.53, p<0.05). Sensory thresholds did not differ between patients and controls but were related to gastrointestinal symptom severity and cirrhosis severity scores in the patients. Conclusions. Gastric accommodation is increased in cirrhotic patients but there seems to be some disturbance in its relation to energy intake. The satiety drinking test is not a good surrogate marker of accommodation in cirrhotic patients. In cirrhosis the severity of gastrointestinal symptoms is related to gastric sensitivity.     

Gastrointestinal motility and gastric emptying after Billroth II gastrectomy in dogs

This study was undertaken to compare the effects of subtotal Billroth II gastrectomy on gastric emptying and gastrointestinal motility with previously published results in intact dogs and in dogs with subtotal Roux-Y gastrectomy. Extraluminal strain gauge transducers were used to study gastrointestinal motility after Billroth II gastrectomy in four conscious dogs. Gastric emptying was measured radiographically. In Billroth II dogs gastric emptying of low-viscosity meals was biphasic with an initial rapid emptying. The addition of nutrients to low-viscosity meals delayed gastric emptying accompanied with reduction in gastric and jejunal motility. Similar to that in Roux-Y dogs, gastric emptying of noncaloric medium-viscosity meals was delayed because of segmenting motor patterns of the jejunal loops, in contrast to the propulsive jejunal motor pattern in intact dogs. Nutrients added to medium-viscosity meals did not change the jejunal motor pattern; gastric emptying was delayed compared with intact dogs. Results show that meal viscosity and jejunal motor pattern influence gastric emptying after Billroth II gastrectomy.This study was supported by the Deutsche Forschungsgemeinschaft, grant Eh 64/3-2.     

Upper abdominal symptoms in patients with Type 1 diabetes: unrelated to impairment in gastric emptying caused by autonomic neuropathy

Aims Diabetic gastroparesis is a common condition occurring in some 30–50% of patients with long-term diabetes. Some studies have found a relationship between autonomic neuropathy and diabetic gastroparesis. In addition to autonomic neuropathy, acute changes in plasma glucose concentration can also affect gastric emptying. The objective was to examine the relationship between autonomic nerve function, glucose concentration, gastric emptying, and upper abdominal symptoms in Type 1 diabetic patients. Methods Gastric emptying of solids and liquids was measured with scintigraphy in 27 patients with longstanding Type 1 diabetes with upper abdominal symptoms. Autonomic nerve function was examined by standardized cardiovascular tests, and plasma glucose concentrations were measured during scintigraphy. Severity of abdominal symptoms and quality of life were explored by validated questionnaires. Results Seven patients (26%) had delayed gastric emptying of solids and three (11%) of liquids. Mean gastric half-emptying time of solids was 128 ± 116 min and of liquids 42 ± 30 min. Of the 26 patients undergoing tests, 16 (62%) had autonomic nerve dysfunction. Autonomic neuropathy score (1.6 ± 1.7) correlated positively with the gastric emptying rate of solids (P = 0.006), a rate unrelated to symptom scores or plasma glucose concentrations during scintigraphy. Quality of life in patients with abdominal symptoms was lower than in the normal Finnish population. Conclusions Impaired gastric emptying of solids in patients with Type 1 diabetes is related to autonomic neuropathy, but not to actual glycaemic control. The upper abdominal symptoms observed in these patients cannot be explained, however, by impaired gastric emptying.     

Gastric and oesophageal emptying in patients with Type 2 (non-insulin-dependent) diabetes mellitus

Summary Gastric emptying of a digestible solid and liquid meal and oesophageal emptying of a solid bolus were measured with scintigraphic techniques in 20 randomly selected Type 2 (non-insulin-dependent) diabetic patients receiving oral hypoglycaemic therapy and 20 control subjects. In the diabetic patients, the relationships between oesophageal emptying, gastric emptying, gastrointestinal symptoms, autonomic nerve function and glycaemic control were examined. The percentage of the solid meal remaining in the stomach at 100 min (p<0.001), the 50% gastric emptying time for the liquid meal (p<0.05) and oesophageal emptying (p<0.05) were slower in the diabetic patients compared to the control subjects. Scores for upper gastrointestinal symptoms and autonomic nerve dysfunction did not correlate significantly (p>0.05) with oesophageal, or gastric emptying. The 50% gastric emptying time for the liquid meal was positively related (r=0.58, p<0.01) to the plasma glucose concentration at the time of the performance of the gastric emptying test and the lag period, before any solid food emptied from the stomach, was longer (p<0.05) in subjects with plasma glucose concentrations during the gastric emptying measurement greater than the median, compared to those with glucose concentrations below the median. These results indicate that delayed gastric and oesophageal emptying occur frequently in Type 2 diabetes mellitus and that delayed gastric emptying relates, at least in part, to plasma glucose concentrations.     

肝病患者的胃动力障碍及西沙必利的改善作用

本文利用B型超声方法检测了20名正常志愿者及50例肝硬化、肝癌患者的胃液体排空功能,同时观察单剂量西沙必利对患者胃排空的影响。结果显示正常胃液体半排空时间(T1/2)为13.90±4.30分钟,肝硬化患者为39.36±12.30分钟,肝癌患者为40.50±8.91分钟,病人与正常对照之间有非常显著的差别。口服西沙必利10mg半小时后患者T1/2明显缩短至24.33±11.17分钟,P<0.05。从而说明了慢性肝病患者胃动力障碍的存在,从另一角度解释了部分肝硬化、肝癌病人的消化道症状,并提示西沙必利对这种障碍的改善作用,为该类病人临床应用西沙必利缓解症状提供了理论依据。     

肝硬化患者脾肝体积比与食管胃底静脉曲张的关系

目的探讨脾肝体积比在预测静脉曲张程度中的价值。方法对51例确诊的肝硬化患者进行胃镜和增强CT检查,将食管胃底静脉曲张程度分级并计算患者的脾肝体积比;比较这两个指标的相关性和各级静脉曲张患者的脾肝体积比。结果食管胃底静脉曲张的分级与脾肝体积比相关性明显(t=0.693,P<0.001)。各级食管胃底静脉曲张之间的脾肝体积比差异均有统计学意义。结论肝硬化患者随着脾肝体积比值的升高,静脉曲张程度加重,脾肝体积比可以作为无创性检测手段判断静脉曲张程度,为进一步的工作打下了一定的基础。     

Changes in liquid emptying in migraine patients: diagnosed with liquid phase gastric emptying scintigraphy

Gastric stasis is suspected mostly to be encountered during acute migraine attack. The aim of this study is to evaluate the liquid phase gastric emptying and motility in migraine patients in ictal and interictal periods in comparison to normal subjects with gastric emptying scintigraphy. Seven women with migraine and age, sex matched controls who applied to the Neurology Department from May 2009 to May 2010 were compared. Gastric emptying study with a standard liquid was performed one time in the non-migraineur group and two times in the migraineur group. Non-migraineur controls and migraineurs were compared. The mean T1/2 was longer in ictal period in migraineurs. The T1/2 of migraineurs interictally and the control groups were similar. The T1/2 of migraineurs ictally and migraineurs interictally were also compared. We also considered the percentage of the radioactive material remaining in the stomach. There were no significant differences between non-migraineurs and migraineurs interictally. However, increased amount of radioactive material remaining in the stomach was observed in migraineurs ictally. We concluded that the liquid emptying was delayed in spontaneous migraine attacks in migraine without aura, however in the interictal period the emptying of liquids did not differ between migraineurs and non-migraineurs.     

老年肝硬化患者不同类型食物胃排空时间与血清NO关系初步探讨

目的 研究老年肝硬化患者不同类型食物胃排空时间及其与m清NO水平关系。方法 分别应用实时超声法和放射学方法对30例老年肝硬化患者（Child—PughA级9例,B级13例,C级8例）和30例健康志愿者进食液体和半固体食物后胃排空时间进行测定,并测定其空腹血清NO浓度。结果 肝硬化患者胃液体半排空时间为47．3±6．9min,而进食10mm小钡条和半固体标准餐混合物后胃排空时间为6．9±1．9h;健康对照组则分别为26．4±5．3min和4．7±1．1h。血清NO浓度患者组与对照组分别为67．9±7．3umol／L及48．8±6．2umol／L,差异均有统计学意义。而Child A,B,C三组之间差异无统计学意义。结论 老年肝硬化患者不同类型食物胃排空时间均有延迟,NO在动力延缓中可能起着重要的作用。实时超声法和放射学方法简单有效。     

Effect of hepatic collateral hemodynamics on gastric mucosal blood flow in patients with liver cirrhosis

The dependence of the gastric mucosal change in liver cirrhosis on the extrahepatic collaterals is still unknown. Therefore we studied the influence of these collateral hemodynamics on gastric mucosal blood flow and gastric mucosal lesions. The subjects were 23 cirrhotic patients and were divided into two groups by the findings of percutaneous transhepatic portography. The first group consisted of 14 cases whose extrahepatic collaterals were via esophageal varices (group I). The second group included 9 cases having collaterals other than esophageal varices (group II). Multiple red spots were observed in 13 of 14 cases in group I, and two of nine cases in group II. Gastric mucosal blood flow was 2.0±0.9 volts (mean±sd) in group I, 4.0±1.2 in group II. A statistically significant difference was observed between groups I and II. Gastric mucosal blood flow was not significantly correlated with portal venous pressure in group I. It is concluded that, in liver cirrhosis, gastric mucosal blood flow is changeable according to the types of the extrahepatic collaterals.     

Effects of nutrients on gastrointestinal motility and gastric emptying after Billroth-I gastrectomy in dogs

We wanted to clarify the way in which nutrients influence gastrointestinal motility and gastric emptying following distal gastrectomy with Billroth-I gastroduodenostomy. Four gastrectomized dogs were equipped with extraluminal strain gauge transducers. Gastric emptying was measured radiographically. Four intact dogs were used as controls for emptying studies. Following gastrectomy, gastric emptying of both acaloric and nutrient meals was rapid in the initial period of the experiments. Gastric outflow was supported by propagating duodenal contractions. Compared with control dogs, the early emptying of nutrient meals was accelerated. In the following period, nutrients markedly slowed gastric emptying compared with acaloric meals due to a segmenting contractile pattern of the duodenum and a significant diminution of gastrointestinal motility. Results suggest that after Billroth-I gastrectomy (1) the control of gastric emptying by nutrients acts too late to slow the initial enhanced gastric outflow, and (2) the duodenal contractile patterns influence gastric emptying.The study was supported by the Deutsche Forschungsgemeinschaft, grant Eh 64/3-1.     

肝硬化患者体表胃电图参数与肝功能损害程度的相关性研究

探讨肝硬化患者体表胃电图参数变化与肝功能及检验指标间的关系。对63例肝硬化患者和20例健康志愿者进行体表胃电图记录和化验检查。将健康对照组、Child-pugh分级A级、B级、C级四级受试者进行两两比较,主频和胃电节律紊乱百分比均有显著差异;胃电节律紊乱百分比与肝功能检验指标进行相关性分析,发现白蛋白和血小板计数与胃电节律紊乱百分比存在直线负相关关系(r分别为-0.723和-0.704)。1.肝硬化患者存在明显胃电节律紊乱,并随肝功能损害程度加重而加重;2.白蛋白和血小板计数与肝硬化患者胃电节律紊乱关系密切,可用于判断肝硬化患者胃动力障碍情况。     

肝硬化食管静脉曲张的替代诊断方法

食管静脉曲张(EV)破裂出血是肝硬化最为严重的并发症之一。上消化道内镜(UGE)是诊断EV的金标准,但为侵袭性检查。目前,已经报道了很多诊断EV的替代方法,包括血清学模型、超声指标、肝脏及脾脏硬度检测、食管胶囊内镜、核磁共振和CT等。综述了这些替代方法诊断EV的准确度及其临床意义。认为超声指标(脾门指数、门静脉充血指数及血小板与脾直径比值)、脾脏硬度检测、CT和食管胶囊内镜诊断EV的准确度较高,故可考虑应用于临床实践以减少UGE的使用。     

Delayed gastric emptying after pancreaticoduodenectomy: A study of the national surgical quality improvement program

BackgroundDelayed gastric emptying (DGE) remains common after pancreaticoduodenectomy (PD). Risk factors for DGE have been difficult to identify due to a lack of a standard definition. The purpose of this study was to identify factors associated with DGE using a standard definition across a national cohort of patients.MethodsA retrospective cohort study of patients who underwent PD from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific module was performed. Multivariable (MV) regression was used to determine perioperative risk factors for DGE.ResultsOf 10,249 patients undergoing PD, 16.6% developed DGE and were older (65.3 vs. 64.3 years), more often male (62.5% vs. 51.9%), overweight/obese (66.7% vs. 61.3%), and American Society of Anesthesiologist (ASA) class 3 (80.0% vs. 76.0%). Rates of pylorus preservation (41.4% vs. 38.7%) were higher, and median operative time (373 vs. 354 min) longer. On MV analysis, age≥65 years [OR 1.26 (95%CI 1.13–1.41)], male sex [OR 1.54 (95%CI 1.38–1.72), body mass index (BMI) > 30 [OR 1.22 (95%CI 1.06–1.40)], ASA class≥3 [OR 1.24 (95%CI 1.08–1.42)], pylorus preservation [OR 1.08 (95%CI 1.02–1.14)], and longer operative time [OR 1.26 (95%CI 1.13–1.40)] remained associated with DGE. Preoperative chemotherapy was associated with decreased risk of DGE [OR 0.77 (95%CI 0.64–0.93)].ConclusionIn this national, multicenter cohort of patients undergoing PD, 16.6% of patients developed DGE based on a standardized definition. Perioperative factors including age, BMI, ASA class, pylorus preservation, and operative time were associated with increased risk of DGE. Further research is warranted to identify opportunities for prevention via preoperative rehabilitation strategies and treatment.     

Abnormal gastric myoelectrical activity and delayed gastric emptying in patients with symptoms suggestive of gastroparesis

Gastric myoelectrical activity modulates gastric motor activity. Abnormalities in gastric myoelectrical activity may be associated with gastric motility disorders. The aim of this study was to investigate the correlation of gastric myoelectrical activity with gastric emptying in symptomatic patients with and without gastroparesis. Ninety-seven patients with symptoms suggestive of gastroparesis participated in the study. Gastric myoelectrical activity was recorded using surface electrogastrography. The electrogastrogram (EGG) was recorded for 30 min in the fasting state and for 120 min after a solid test meal. Gastric emptying of the solid meal was simultaneously monitored for 120 min. Patients with delayed gastric emptying showed a significantly lower percentage of normal gastric slow waves (P<0.03) and a significantly reduced increase of the dominant power in the postprandial EGG (P<0.02). Postprandial EGG parameters were found to be able to predict delayed emptying of the stomach. Postprandial gastric dysrhythmia predicts delayed gastric emptying with an accuracy of 78%, while the abnormality in postprandial EGG power predicts delayed gastric emptying with an accuracy of 75%. All patients with abnormalities in both the rhythmicity and the power had delayed gastric emptying. Patients with delayed gastric emptying have a lower percentage of normal gastric slow waves in the EGG and a lower postprandial increase in the dominant power. Abnormalities in the postprandial EGG seem to be able to predict delayed emptying of the stomach. However, a normal EGG does not seem to guarantee normal emptying of the stomach.     

Influence of blood glucose levels on rat liquid gastric emptying

The glycemic influence on liquid gastric emptying in rats was studied. Diabetic hyperglycemia was induced by streptozotocin intravenous injection seven days before the motility experiment. Some streptozotocin-treated rats further received a daily insulin injection (2.5 or 10 IU/kg). Immediate hyperglycemia was induced in a separate group of rats by continuous intravenous glucose infusion (44 or 88 mg/kg/min) 10 min before the experiment. Rats were killed 15 min after radiochromium feeding; then the radioactivity of stomach and small intestine were counted to obtain the gastric emptying value. Emptying in diabetic rats was delayed compared with controls (mean±se: 40.9±2.6% vs. 54.2±2.8%,P<0.01). Low-dose insulin treatment reversed the impairment, while high-dose treatment even enhanced emptying. Immediate hyperglycemia induced with two glucose infusions also inhibited gastric emptying. Present results indicate that hyperglycemia elicited with any hyperglycemic model is at least one of the important mechanisms to delay liquid gastric emptying.This study was supported by the National Science Council, Republic of China, grant NSC 84-2331-B-075-68.