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Long Term Efficacy of Gastric Electrical Stimulation in Intractable Nausea and Vomiting
0.01) , satiety (60%; p=0.01), bloating (31%; p=0.03), regurgitation (25%; p=0.05) and epigastric pain (23%; p=0.04). Over 5 years, 12 patients out of 15 reported a 50 % of improvement with a global satisfaction rated at 68 ± 6 %. In intention to treat, 12 patients out of 22 were improved over (55%) 5 years. Univariate analysis failed to identify factors associated with improvement over 5 years, while long term improvement was correlated with the severity of symptoms and their improvement at 6 months. Last, patients with delayed gastric emptying or with normal gastric emptying rate before surgery were improved over 5 years in a similar manner (respectively 58% versus 50% in intention to treat). Conclusion GES is a safe and effective therapy on the long term in patients with medically refractory nausea and vomiting, with a efficacy over 50% beyond 5 years in intention to treat. Gastric emptying measured before implantation did not influence the response rate over 5 years. Tu1383 Effect of Peppermint Oil on Gastric Accommodation to a Meal, Compliance and Sensitivity to Balloon Distension in Health Athanasios A. Papathanasopoulos, Alessandra Rotondo, Rita Vos, Pieter Janssen, Emidio Scarpellini, Pieter Vanden Berghe, Werend Boesmans, Jan F. Tack Background and aims: Animal studies have shown that menthol reduces intestinal segmentation/motility, an effect that is probably mediated by transient receptor potential (TRP) channels. Peppermint oil (PO), with menthol as a major constituent, is widely used as a spasmolytic agent in irritable bowel syndrome. Recent data have implicated tone of the proximal stomach in the modulation of satiation during meal ingestion. We set out to investigate the effect of PO on gastric sensorimotor functions in health. Methods: Ten fasted healthy volunteers (HV, mean age±SEM: 33±2.4, BMI: 23±0.8, 6 female) underwent a gastric barostat study in a randomized controlled crossover design. Intragastric balloon volume was recorded with pressure maintained at intra-abdominal pressure +2 mmHg. HVs consumed a 300-Kcal liquid meal 60 min after ingesting a PO capsule (182 mg) or placebo; on separate visits, stepwise isobaric distensions were performed before and 60 min post-medication. HVs scored hunger and 9 epigastric symptoms on a visual analogue scale (VAS). Barostat parameters and VAS scores were compared between placebo and PO with t-test. Results: During isobaric distension, no significant differences were demonstrated in fundic compliance between placebo and PO pre- (54.4±4.6 vs. 56.7±10.8 mL mmHg-1, p=0.84), and postmedication (54.1±2.3 vs. 55.1±7.9 mL mmHg-1, p=0.97). Accordingly, threshold pressures did not differ pre- (11.1±0.8 vs. 12±1.3 mmHg, p=0.51) and post-medication (10.6±0.4 vs. 11.7±0.9 mmHg, p=0.20), and discomfort pressures did not differ pre- (18.6±0.5 vs. 25.3±5.9 mmHg, p=0.29) and post-medication (17.7±0.9 vs. 18±1 mmHg, p=0.87). Similarly, threshold volumes were comparable between placebo and PO before (193.1±38.6 vs. 175.2±47.6 mL, p=0.63) and post-medication (217.3±37.8 vs. 293.6±80.8, p=0.43), and discomfort volumes were similar before (614.6±65.6 vs. 588±64.8 mL, p=0.56) and postdrug (617.3±40.2 vs. 582.8±70.6 mL, p=0.71). We observed no significant differences in balloon volume between placebo and PO at baseline (p=0.87, see Table), post-medication (p=0.97), and post-meal (p=0.84). Accordingly, meal-induced accommodation (delta volume pre- and post-meal) was not significantly different (p=0.78). In contrast, pre-meal cumulative VAS scores were significantly higher after placebo compared to PO for hunger (p<0.05) and appetite (p=0.01). Furthermore, post-meal cumulative VAS scores were significantly higher after placebo compared to PO for fullness sensation (p<0.05) and nausea (p<0.05). Conclusions: After single-dose administration, PO reduces hunger and decreases meal-related symptoms in health, without inducing significant effects on sensitivity to gastric distention or gastric accommodation.
Tu1381 Rumination Variations Emily Tucker, Jeff Wright, Mark R. Fox Introduction: Rumination syndrome is the voluntary, albeit subconscious return of gastric content to the mouth. It is socially disabling, often leads to repeated, non-diagnostic investigations and can have significant morbidity. High Resolution Manometry (HRM) with observations after drinking or a test meal is a simple, objective way of establishing the diagnosis. A variety of behaviours and manometric findings are associated with rumination. This study describes how these influence patient presentation and may affect treatment. Methods: A retrospective review of 20 patients (M=8, F=12, age 21-68) referred for HRM with a final diagnosis of rumination was completed. Predominant presenting symptoms included regurgitation (n=4), vomiting (n=9), or suspicion of rumination (n=7). Recurrent belching was also a feature in some (n=7). In addition to the return of gastric content, patients described typical dyspeptic symptoms (n=17) and reflux symptoms (n=3). Results: HRM revealed normal motility in 14/20, hypotensive in 4/20 and hypertensive in 2/20. Rumination was observed during water swallows in 10, following multiple water swallows in 2 and after a test meal in 8 patients. In patients with dyspepsia, HRM demonstrated classical rumination (“R waves”) in 10/17 (59%), powerful contraction of abdominal muscles forced gastric content across the lower oesophageal sphincter (LOS). Five patients ruminated following a swallow while the LOS was relaxed, making it easy for gastric content to pass. One ruminated with a closed upper oesophageal sphincter leading to bolus “trapping” and pain, at which point she would induce vomiting. One patient, who had fundoplication as a child, would cough to create the abdominal pressure required to overcome the resistance formed by the wrap. Some patients with prominent belching and dyspepsia (4/7) exhibited supra-gastric belching with rumination. Air was sucked into the oesophagus by creating a negative intrathoracic pressure and expelled, without passing the LOS. In patients with reflux symptoms (n=3), all ruminated a few seconds following the appearance of transient LOS relaxation with common cavity (reflux). Unlike classical rumination these events were often high volume, occur after meals, on exertion and in the supine position. Conclusion: HRM facilitates diagnosis and reveals the behaviour associated with rumination. Ingestion of a test drink and meal increases test sensitivity. Three key “rumination variations” were identified; Dyspepsia with typical rumination - Dyspepsia with rumination and supra-gastric belching - Reflux related rumination All may benefit from biofeedback therapy; however, the focus may differ for rumination and supra-gastric belching. Visceral analgesics may ease dyspepsia but proton pump inhibitors or even anti-reflux surgery may be appropriate for reflux related rumination. Tu1382
Tu1384
Long Term Efficacy of Gastric Electrical Stimulation in Intractable Nausea and Vomiting Guillaume Gourcerol, Emmanuel Huet, Nathalie Bertiaux Vandaële, Ulriikka Chaput, Valérie Bridoux, Francis Michot, Anne-Marie Leroi, Philippe R. Ducrotté
Small Intestine Bacterial Overgrowth (SIBO) is Common in Patients With Idiopathic Gastroparesis Lubin F. Arevalo, Aaron B. Trimble, Jody Hirsch, Brad M. Dworkin BACKGROUND : The etiology of small intestine bacterial overgrowth (SIBO) is complex, and associated with immunodeficiency disorders, anatomical abnormalities and motility disorders including IBS. The symptomatic spectrum of SIBO may be similar to those observed in patients with gastroparesis. It is also known that etiologies for gastroparesis could predispose to SIBO. The aim of our study was to assess the prevalence of SIBO in a group of patients with largely idiopathic gastroparesis. METHODS: We retrospective analyzed 23 patients with gastroparesis in whom SIBO study was conducted due to persistent symptoms of abdominal pain, irregular bowel function and bloating despite prokinetic therapy. Associated factors including PPI status, use of narcotic medications and constipation were analyzed. RESULTS: Twenty three patients with gastroparesis underwent SIBO study by Lactulose breath test .Hydrogen and methane were measured. A test was considered positive if a 20ppm rise was seen by 120 minutes time. 19 (82%) patients were female and 4 (18%)
Abstract Gastric electrical stimulation (GES) has become a new alternative in the treatment of medically refractory nausea and vomiting, especially in patients with gastroparesis. Although the efficacy of the technique has been reported in short term studies, there is to date a lack of data on the long term improvement of nausea and vomiting by GES in patients with delayed or normal gastric emptying rate. Methods From 1998 to 2005, 26 patients were implanted at our center for severe and chronic nausea and/or vomiting refractory to standard medical management. Patients were evaluated at baseline, 6 months and beyond 5 years after implantation (mean follow-up 83 ± 4 months) using symptomatic scale from 0 (worse) to 4 (best) and the GIQLI quality of life scale. Results Out of the 26 patients, 4 were lost, 6 were explanted for absence of improvement, and 1 patient died (cause of death was unrelated to the stimulator). Out of the 15 patients evaluated over 5 years, the GIQLI scale was 31% improved (p=0.005), as well as nausea, (29%; p=0.04), vomiting (43%; p=
S-811
AGA Abstracts
AGA Abstracts
electrical stimulation via surface electrodes placed at acupoints, was as effective as EA in improving intestinal dysmotility in dogs. Methods: Six female dogs chronically implanted with a duodenal cannula, a proximal colon cannula and intestinal serosal electrodes were studied in six randomized sessions: EA, TEA, sham, atropine+EA, atropine+TEA and atropine+sham. Intestinal myoelectrical activity (IMA), heart rate variability (HRV), small bowel transit (SBT) and contractions in the fed state were evaluated. Each session was composed of 4 periods: 30min baseline after the meal, 30 min during rectal distention (RD, 140ml) with EA, TEA or sham, 30 min without RD but with EA or TEA or sham, and 90 min recovery. EA or TEA was performed at ST-36 (Zusanli) bilaterally. The electrical stimulation parameters were the same for EA and TEA: pulse train of 2s-on 3s-off, 25 Hz and 6 mA. Atropine 0.02mg/kg was administrated intravenously prior to the feeding. The IMA was recorded via the serosal electrodes. The HRV signal was derived from the ECG and subjected to spectral analysis for the assessment of sympathovagal activity. The SBT was measured by injection of phenol red into the duodenal cannula and observation of its first appearance from the colon cannula. Intestinal contractions were evaluated by manometry via an intraluminal catheter placed through the duodenal cannula. Results: 1) RD at a volume of 140 ml suppressed intestinal contraction (contractile index: 6.2 ± 0.3 vs. 8.5 ± 0.3 at baseline, P < 0.001). Both EA and TEA improved intestinal contractions (7.9 ± 0.2 with EA and 7.8 ± 0.3 with TEA vs. 6.2 ± 0.3 with control, P < 0.001). 2) RD reduced the percentage of normal intestinal slow waves from 92.0 ± 4.0% to 51.1 ± 3.1 (P < 0.01) that was increased to 68.7 ± 6.2% with EA and to 61.1 ± 4.1% with TEA (P < 0.05). 3) EA and TEA reduced the small bowel transit time (SBTT) ( 100.8 ± 15.3 min with EA, 136.7 ± 8.0 min with TEA vs. 190.8 ± 9.3 min in sham, P < 0.01), and this effect was partially blocked by Atropine. 4) The HRV analysis showed increased vagal activity with both EA and TEA (P = 0.03 via sham). 5) No significant differences were noted in the ameliorating effects of acupuncture on intestinal motility between EA and TEA (P > 0.05). Conclusion: EA at ST36 is able to improve the RD-induced impairment in intestinal motility and the ameliorating effect is at least partially mediated via the vagal pathway. Needless TEA is as effective as EA via acupuncture needles. The findings suggest that needleless TEA may be an attractive method for treating intestinal motility disorders.
Tu1381 Rumination Variations Emily Tucker, Jeff Wright, Mark R. Fox Introduction: Rumination syndrome is the voluntary, albeit subconscious return of gastric content to the mouth. It is socially disabling, often leads to repeated, non-diagnostic investigations and can have significant morbidity. High Resolution Manometry (HRM) with observations after drinking or a test meal is a simple, objective way of establishing the diagnosis. A variety of behaviours and manometric findings are associated with rumination. This study describes how these influence patient presentation and may affect treatment. Methods: A retrospective review of 20 patients (M=8, F=12, age 21-68) referred for HRM with a final diagnosis of rumination was completed. Predominant presenting symptoms included regurgitation (n=4), vomiting (n=9), or suspicion of rumination (n=7). Recurrent belching was also a feature in some (n=7). In addition to the return of gastric content, patients described typical dyspeptic symptoms (n=17) and reflux symptoms (n=3). Results: HRM revealed normal motility in 14/20, hypotensive in 4/20 and hypertensive in 2/20. Rumination was observed during water swallows in 10, following multiple water swallows in 2 and after a test meal in 8 patients. In patients with dyspepsia, HRM demonstrated classical rumination (“R waves”) in 10/17 (59%), powerful contraction of abdominal muscles forced gastric content across the lower oesophageal sphincter (LOS). Five patients ruminated following a swallow while the LOS was relaxed, making it easy for gastric content to pass. One ruminated with a closed upper oesophageal sphincter leading to bolus “trapping” and pain, at which point she would induce vomiting. One patient, who had fundoplication as a child, would cough to create the abdominal pressure required to overcome the resistance formed by the wrap. Some patients with prominent belching and dyspepsia (4/7) exhibited supra-gastric belching with rumination. Air was sucked into the oesophagus by creating a negative intrathoracic pressure and expelled, without passing the LOS. In patients with reflux symptoms (n=3), all ruminated a few seconds following the appearance of transient LOS relaxation with common cavity (reflux). Unlike classical rumination these events were often high volume, occur after meals, on exertion and in the supine position. Conclusion: HRM facilitates diagnosis and reveals the behaviour associated with rumination. Ingestion of a test drink and meal increases test sensitivity. Three key “rumination variations” were identified; Dyspepsia with typical rumination - Dyspepsia with rumination and supra-gastric belching - Reflux related rumination All may benefit from biofeedback therapy; however, the focus may differ for rumination and supra-gastric belching. Visceral analgesics may ease dyspepsia but proton pump inhibitors or even anti-reflux surgery may be appropriate for reflux related rumination. Tu1382
Tu1384
Long Term Efficacy of Gastric Electrical Stimulation in Intractable Nausea and Vomiting Guillaume Gourcerol, Emmanuel Huet, Nathalie Bertiaux Vandaële, Ulriikka Chaput, Valérie Bridoux, Francis Michot, Anne-Marie Leroi, Philippe R. Ducrotté
Small Intestine Bacterial Overgrowth (SIBO) is Common in Patients With Idiopathic Gastroparesis Lubin F. Arevalo, Aaron B. Trimble, Jody Hirsch, Brad M. Dworkin BACKGROUND : The etiology of small intestine bacterial overgrowth (SIBO) is complex, and associated with immunodeficiency disorders, anatomical abnormalities and motility disorders including IBS. The symptomatic spectrum of SIBO may be similar to those observed in patients with gastroparesis. It is also known that etiologies for gastroparesis could predispose to SIBO. The aim of our study was to assess the prevalence of SIBO in a group of patients with largely idiopathic gastroparesis. METHODS: We retrospective analyzed 23 patients with gastroparesis in whom SIBO study was conducted due to persistent symptoms of abdominal pain, irregular bowel function and bloating despite prokinetic therapy. Associated factors including PPI status, use of narcotic medications and constipation were analyzed. RESULTS: Twenty three patients with gastroparesis underwent SIBO study by Lactulose breath test .Hydrogen and methane were measured. A test was considered positive if a 20ppm rise was seen by 120 minutes time. 19 (82%) patients were female and 4 (18%)
Abstract Gastric electrical stimulation (GES) has become a new alternative in the treatment of medically refractory nausea and vomiting, especially in patients with gastroparesis. Although the efficacy of the technique has been reported in short term studies, there is to date a lack of data on the long term improvement of nausea and vomiting by GES in patients with delayed or normal gastric emptying rate. Methods From 1998 to 2005, 26 patients were implanted at our center for severe and chronic nausea and/or vomiting refractory to standard medical management. Patients were evaluated at baseline, 6 months and beyond 5 years after implantation (mean follow-up 83 ± 4 months) using symptomatic scale from 0 (worse) to 4 (best) and the GIQLI quality of life scale. Results Out of the 26 patients, 4 were lost, 6 were explanted for absence of improvement, and 1 patient died (cause of death was unrelated to the stimulator). Out of the 15 patients evaluated over 5 years, the GIQLI scale was 31% improved (p=0.005), as well as nausea, (29%; p=0.04), vomiting (43%; p=
S-811
AGA Abstracts
AGA Abstracts
electrical stimulation via surface electrodes placed at acupoints, was as effective as EA in improving intestinal dysmotility in dogs. Methods: Six female dogs chronically implanted with a duodenal cannula, a proximal colon cannula and intestinal serosal electrodes were studied in six randomized sessions: EA, TEA, sham, atropine+EA, atropine+TEA and atropine+sham. Intestinal myoelectrical activity (IMA), heart rate variability (HRV), small bowel transit (SBT) and contractions in the fed state were evaluated. Each session was composed of 4 periods: 30min baseline after the meal, 30 min during rectal distention (RD, 140ml) with EA, TEA or sham, 30 min without RD but with EA or TEA or sham, and 90 min recovery. EA or TEA was performed at ST-36 (Zusanli) bilaterally. The electrical stimulation parameters were the same for EA and TEA: pulse train of 2s-on 3s-off, 25 Hz and 6 mA. Atropine 0.02mg/kg was administrated intravenously prior to the feeding. The IMA was recorded via the serosal electrodes. The HRV signal was derived from the ECG and subjected to spectral analysis for the assessment of sympathovagal activity. The SBT was measured by injection of phenol red into the duodenal cannula and observation of its first appearance from the colon cannula. Intestinal contractions were evaluated by manometry via an intraluminal catheter placed through the duodenal cannula. Results: 1) RD at a volume of 140 ml suppressed intestinal contraction (contractile index: 6.2 ± 0.3 vs. 8.5 ± 0.3 at baseline, P < 0.001). Both EA and TEA improved intestinal contractions (7.9 ± 0.2 with EA and 7.8 ± 0.3 with TEA vs. 6.2 ± 0.3 with control, P < 0.001). 2) RD reduced the percentage of normal intestinal slow waves from 92.0 ± 4.0% to 51.1 ± 3.1 (P < 0.01) that was increased to 68.7 ± 6.2% with EA and to 61.1 ± 4.1% with TEA (P < 0.05). 3) EA and TEA reduced the small bowel transit time (SBTT) ( 100.8 ± 15.3 min with EA, 136.7 ± 8.0 min with TEA vs. 190.8 ± 9.3 min in sham, P < 0.01), and this effect was partially blocked by Atropine. 4) The HRV analysis showed increased vagal activity with both EA and TEA (P = 0.03 via sham). 5) No significant differences were noted in the ameliorating effects of acupuncture on intestinal motility between EA and TEA (P > 0.05). Conclusion: EA at ST36 is able to improve the RD-induced impairment in intestinal motility and the ameliorating effect is at least partially mediated via the vagal pathway. Needless TEA is as effective as EA via acupuncture needles. The findings suggest that needleless TEA may be an attractive method for treating intestinal motility disorders.