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Mo1294 Diabetic Patients' Perceptions Regarding the Impact of Gastroparesis on Diabetes Control
Mo1295
Patients with gastroparesis often have worsening symptoms after meal ingestion. Aim: To evaluate gastrointestinal symptoms during gastric emptying scintigraphy (GES) to better understand symptoms following meal ingestion in patients with diabetic gastroparesis (DG) and idiopathic gastroparesis (IG). Methods: Patients completed the PAGI-SYM questionnaire immediately prior to GES assessing symptom severity over the prior two weeks. During 4 hr low fat EggBeaters meal GES, patients completed an additional questionnaire assessing severity of six symptoms (stomach fullness, nausea, bloating, belching, abdominal pain, abdominal burning) before the meal, immediately after (0 min), and at 30, 60, 120, 180, and 240 minutes after meal ingestion. A Symptom Severity Index (SSI) representing the mean of the 6 symptoms at each time point was calculated. Results: 229 patients had delayed gastric emptying on GES during the period February 2011 to November 2013. Of these, 154 had IG, 53 had DG. 23 patients who had taken narcotics within 2 days prior to GES were excluded. For both IG and DG, SSI increased after ingestion of the meal. There was no difference in postprandial SSI between IG and DG (1.0±0.1 vs 1.1±0.1, p=0.43). Peak SSI occurred at 30 min for IG and 60 min for DG. For each group, stomach fullness was the highest postprandial symptom severity (IG: 2.0±0.1 and DG: 1.9±0.2). For IG, symptoms that increased were stomach fullness (peak at 30 min), bloating (30 min), belching (30 min), abdominal pain (60 min), nausea (60 min), and abdominal burning (60 min). For DG, stomach fullness (peak at 0 min), bloating (60 min), abdominal pain (180 min), belching (180 min), and abdominal burning (180 min) increased (all p<0.05). During GES, % gastric retention (GR) was greater in DG than IG at 3 hours (49±2 vs 41±1; p< 0.01), and 4 hours (34±2 vs 25±1; p<0.01). There was no significant correlation between % GR and SSI at any time point for IG or DG. PAGI-SYM scores correlated with postprandial symptoms of upper abdominal pain (IG: r=0.65; DG: r=0.60), bloating (IG: r=0.69; DG: r= 0.52), stomach fullness (IG: r=0.59; DG: r=0.74), and nausea (IG: r=0.67; DG: r=0.68). They did not, however, correlate with % GR at 2 hours or 4 hours. Conclusions: In patients with gastroparesis, symptoms increase during GES after meal ingestion. Peak symptom severity occurred 30 min after the meal for IG and 60 min after the meal for DG. DG patients had greater gastric retention than IG at 3 and 4 hours. There was no correlation with the symptoms during the test and gastric retention. The postprandial symptoms in gastroparesis correlated with PAGI-SYM assessment of symptoms over the 2 weeks prior to the test. Thus, assessment of symptoms during GES can be performed to capture postprandial symptom severity. The PAGI-SYM appears to capture these postprandial symptoms. Mo1296 EndoFLIP As a Novel Method to Evaluate the Pyloric Sphincter in Patients With Gastroparesis Zubair A. Malik, Abhinav Sankineni, Henry P. Parkman
Mo1294 Diabetic Patients' Perceptions Regarding the Impact of Gastroparesis on Diabetes Control Carol J. Homko, Henry P. Parkman
Endoscopic Functional Luminal Imaging Probe (EndoFLIP) is a technology that has been used to evaluate the LES in achalasia and GERD. EndoFLIP uses 16 sensors inside a balloon that is inflated inside a sphincter and cross-sectional area (CSA), shape, pressure, length, and distensibility are obtained. Prior studies have assessed pyloric sphincter pressures using water perfused manometry, or in some cases, high resolution manometry. Aim: To measure the CSA, shape, pressure, length, and distensibility of the pylorus using EndoFLIP in patients with gastroparesis. Methods: EndoFLIP (Crospon Ltd, Galway, Ireland) was performed in 16 patients (9 idiopathic gastroparesis [IG], 7 diabetic gastroparesis [DG]). Initial endoscopic examination was performed up to the antrum without traversing the pylorus. An EndoFLIP catheter was passed either through a single channel large diameter therapeutic endoscope, or alongside a regular upper endoscope with a suture tied at the distal tip that could be grabbed with biopsy forceps to assist passing the catheter into the pylorus when necessary, or using an External Channel Device EF-800S (Crospon Ltd), all under direct endoscopic visualization (Figure 1). CSA, shape, pressure, and diameter of pylorus was measured at 20cc, 30cc, 40cc and 50cc balloon volume distensions. Distensibility was calculated as minimum CSA divided by the pressure at each balloon fill volume. Length of the pyloric sphincter was assessed visually from the EndoFLIP images. Results: Passing the catheter through the single channel therapeutic endoscope appeared to be the easiest method for traversing the pylorus. The volume of 20cc appeared too small to capture pyloric sphincter contour, whereas 30cc, 40cc, and 50cc have better images displaying pyloric sphincter (Figure 2). The pyloric sphincter contour was seen best at 40cc balloon distension (diameter 13.0±0.9mm, CSA 144.6±19.8mm2, pressure 16.8±2.3mmHg, length 1.7±0.8cm, distensibility 13.6±3.4mm2/mmHg). There was a wide range seen in diameter (5.6-20.6mm) and distensibility (1-55 mm2/mmHg) of the pylorus; low distensibility suggesting a "stiff" pylorus whereas high distensibility suggesting an "open" or "floppy" pylorus. DG tended to have a smaller diameter pylorus (11.6±1.3mm vs 14.3±2.6mm; p=0.16) with less distensibility (10.4±4.6mm2/mmHg vs 16.9±5.8mm2/mmHg; p=0.20) compared to IG. Conclusions: EndoFLIP is a novel technique that can be used to assess pyloric diameter, CSA, length, pressure, and distensibility. No significant differences were seen when comparing diabetic and idiopathic gastroparetics, but this may be due to the small study size of this preliminary trial. Further studies are needed to characterize these findings in normal subjects and in different etiologies of gastroparesis. This technology will be of benefit to help select patients with pyloric sphincter abnormalities.
Gastroparesis is a complication of diabetes mellitus. Gastroparetic symptoms of nausea, vomiting, and early satiety and the delayed gastric emptying can make glucose control difficult. The impact of gastroparesis on diabetes management and control from the patient perspective has not been systematically studied. The aim of this study was to identify patient perceptions regarding the impact of gastroparesis on managing their diabetes. Methods: Diabetic patients being referred for gastroparesis and having delayed gastric emptying on gastric scintigraphy were enrolled in this prospective study. Clinical and demographic characteristics were obtained by interview, medical record and laboratory reports. Gastroparetic symptom severity was assessed with the Patient Assessment of Upper GI Symptoms (PAGI-SYM) on a none (0) to very severe (5) scale. A questionnaire developed for this study examined the impact on gastroparesis on diabetes related symptoms and control, with responses ranging from strongly disagree (-2) to strongly agree (+2). Results: 33 individuals with diabetic gastroparesis (25 T1DM and 8 T2DM; average age 44±3 (SEM) years; 26 females) participated. All but 3 patients were taking insulin. Mean HgbA1c was 8.1±0.2% with range from 6.6 to 11.2%. Gastric retention at 4 hrs averaged 37±4% (normal<10%). Duration of diabetes averaged 18.5±2.0 years and gastroparetic symptoms 5.6±1.7 years. Patients rated their most severe symptoms of gastroparesis as nausea (3.7±0.2), early satiety (3.7±0.2), and postprandial fullness (3.8±0.2). Patients with T1DM had greater gastric retention (41±4 vs 23±4% retention at 4 hrs; p<0.05), greater HgbA1c (8.4±1.7 vs 6.3±0.9; p=0.06), and greater vomiting severity (2.7±0.4 vs 0.9±0.6; p=0.03) than patients with T2DM. The majority of diabetic subjects identified that since their diagnosis of gastroparesis, their diabetes was more difficult to control (23 of 33 patients) and that extra time and effort for care of their diabetes was required (22 of 33). In contrast to T2DM, patients with T1DM expressed that since developing gastroparesis, their blood sugars have been higher (0.7±0.3 vs 0.0±0.5; p=0.20), have had more frequent episodes of hypoglycemia (0.6±0.2 vs -0.6±0.4; p<0.01), and found their gastroparetic symptoms worsened with if blood sugars were too high (0.8±0.2 vs 0.1±0.5; p=0.10). Few diabetic patients of either group (7 of 33) felt that their gastroparesis symptoms improved if blood sugars were controlled. Conclusions: Gastroparesis has a significant impact on patients' perceived ability to self-manage and control their diabetes. T1DM patients, in particular, associate their gastroparesis with episodes of hyper- and hypo-glycemia, and find their gastroparetic symptoms worsen with poor control. Future research should focus on strategies to support patient self-management for diabetics with gastroparesis.
S-611
AGA Abstracts
AGA Abstracts
Symptoms Following Meal Ingestion During Gastric Emptying Scintigraphy in Patients With Gastroparesis Akil Hassam, Saraswathi Arasu, Zubair A. Malik, Alan H. Maurer, Henry P. Parkman
Patients with gastroparesis often have worsening symptoms after meal ingestion. Aim: To evaluate gastrointestinal symptoms during gastric emptying scintigraphy (GES) to better understand symptoms following meal ingestion in patients with diabetic gastroparesis (DG) and idiopathic gastroparesis (IG). Methods: Patients completed the PAGI-SYM questionnaire immediately prior to GES assessing symptom severity over the prior two weeks. During 4 hr low fat EggBeaters meal GES, patients completed an additional questionnaire assessing severity of six symptoms (stomach fullness, nausea, bloating, belching, abdominal pain, abdominal burning) before the meal, immediately after (0 min), and at 30, 60, 120, 180, and 240 minutes after meal ingestion. A Symptom Severity Index (SSI) representing the mean of the 6 symptoms at each time point was calculated. Results: 229 patients had delayed gastric emptying on GES during the period February 2011 to November 2013. Of these, 154 had IG, 53 had DG. 23 patients who had taken narcotics within 2 days prior to GES were excluded. For both IG and DG, SSI increased after ingestion of the meal. There was no difference in postprandial SSI between IG and DG (1.0±0.1 vs 1.1±0.1, p=0.43). Peak SSI occurred at 30 min for IG and 60 min for DG. For each group, stomach fullness was the highest postprandial symptom severity (IG: 2.0±0.1 and DG: 1.9±0.2). For IG, symptoms that increased were stomach fullness (peak at 30 min), bloating (30 min), belching (30 min), abdominal pain (60 min), nausea (60 min), and abdominal burning (60 min). For DG, stomach fullness (peak at 0 min), bloating (60 min), abdominal pain (180 min), belching (180 min), and abdominal burning (180 min) increased (all p<0.05). During GES, % gastric retention (GR) was greater in DG than IG at 3 hours (49±2 vs 41±1; p< 0.01), and 4 hours (34±2 vs 25±1; p<0.01). There was no significant correlation between % GR and SSI at any time point for IG or DG. PAGI-SYM scores correlated with postprandial symptoms of upper abdominal pain (IG: r=0.65; DG: r=0.60), bloating (IG: r=0.69; DG: r= 0.52), stomach fullness (IG: r=0.59; DG: r=0.74), and nausea (IG: r=0.67; DG: r=0.68). They did not, however, correlate with % GR at 2 hours or 4 hours. Conclusions: In patients with gastroparesis, symptoms increase during GES after meal ingestion. Peak symptom severity occurred 30 min after the meal for IG and 60 min after the meal for DG. DG patients had greater gastric retention than IG at 3 and 4 hours. There was no correlation with the symptoms during the test and gastric retention. The postprandial symptoms in gastroparesis correlated with PAGI-SYM assessment of symptoms over the 2 weeks prior to the test. Thus, assessment of symptoms during GES can be performed to capture postprandial symptom severity. The PAGI-SYM appears to capture these postprandial symptoms. Mo1296 EndoFLIP As a Novel Method to Evaluate the Pyloric Sphincter in Patients With Gastroparesis Zubair A. Malik, Abhinav Sankineni, Henry P. Parkman
Mo1294 Diabetic Patients' Perceptions Regarding the Impact of Gastroparesis on Diabetes Control Carol J. Homko, Henry P. Parkman
Endoscopic Functional Luminal Imaging Probe (EndoFLIP) is a technology that has been used to evaluate the LES in achalasia and GERD. EndoFLIP uses 16 sensors inside a balloon that is inflated inside a sphincter and cross-sectional area (CSA), shape, pressure, length, and distensibility are obtained. Prior studies have assessed pyloric sphincter pressures using water perfused manometry, or in some cases, high resolution manometry. Aim: To measure the CSA, shape, pressure, length, and distensibility of the pylorus using EndoFLIP in patients with gastroparesis. Methods: EndoFLIP (Crospon Ltd, Galway, Ireland) was performed in 16 patients (9 idiopathic gastroparesis [IG], 7 diabetic gastroparesis [DG]). Initial endoscopic examination was performed up to the antrum without traversing the pylorus. An EndoFLIP catheter was passed either through a single channel large diameter therapeutic endoscope, or alongside a regular upper endoscope with a suture tied at the distal tip that could be grabbed with biopsy forceps to assist passing the catheter into the pylorus when necessary, or using an External Channel Device EF-800S (Crospon Ltd), all under direct endoscopic visualization (Figure 1). CSA, shape, pressure, and diameter of pylorus was measured at 20cc, 30cc, 40cc and 50cc balloon volume distensions. Distensibility was calculated as minimum CSA divided by the pressure at each balloon fill volume. Length of the pyloric sphincter was assessed visually from the EndoFLIP images. Results: Passing the catheter through the single channel therapeutic endoscope appeared to be the easiest method for traversing the pylorus. The volume of 20cc appeared too small to capture pyloric sphincter contour, whereas 30cc, 40cc, and 50cc have better images displaying pyloric sphincter (Figure 2). The pyloric sphincter contour was seen best at 40cc balloon distension (diameter 13.0±0.9mm, CSA 144.6±19.8mm2, pressure 16.8±2.3mmHg, length 1.7±0.8cm, distensibility 13.6±3.4mm2/mmHg). There was a wide range seen in diameter (5.6-20.6mm) and distensibility (1-55 mm2/mmHg) of the pylorus; low distensibility suggesting a "stiff" pylorus whereas high distensibility suggesting an "open" or "floppy" pylorus. DG tended to have a smaller diameter pylorus (11.6±1.3mm vs 14.3±2.6mm; p=0.16) with less distensibility (10.4±4.6mm2/mmHg vs 16.9±5.8mm2/mmHg; p=0.20) compared to IG. Conclusions: EndoFLIP is a novel technique that can be used to assess pyloric diameter, CSA, length, pressure, and distensibility. No significant differences were seen when comparing diabetic and idiopathic gastroparetics, but this may be due to the small study size of this preliminary trial. Further studies are needed to characterize these findings in normal subjects and in different etiologies of gastroparesis. This technology will be of benefit to help select patients with pyloric sphincter abnormalities.
Gastroparesis is a complication of diabetes mellitus. Gastroparetic symptoms of nausea, vomiting, and early satiety and the delayed gastric emptying can make glucose control difficult. The impact of gastroparesis on diabetes management and control from the patient perspective has not been systematically studied. The aim of this study was to identify patient perceptions regarding the impact of gastroparesis on managing their diabetes. Methods: Diabetic patients being referred for gastroparesis and having delayed gastric emptying on gastric scintigraphy were enrolled in this prospective study. Clinical and demographic characteristics were obtained by interview, medical record and laboratory reports. Gastroparetic symptom severity was assessed with the Patient Assessment of Upper GI Symptoms (PAGI-SYM) on a none (0) to very severe (5) scale. A questionnaire developed for this study examined the impact on gastroparesis on diabetes related symptoms and control, with responses ranging from strongly disagree (-2) to strongly agree (+2). Results: 33 individuals with diabetic gastroparesis (25 T1DM and 8 T2DM; average age 44±3 (SEM) years; 26 females) participated. All but 3 patients were taking insulin. Mean HgbA1c was 8.1±0.2% with range from 6.6 to 11.2%. Gastric retention at 4 hrs averaged 37±4% (normal<10%). Duration of diabetes averaged 18.5±2.0 years and gastroparetic symptoms 5.6±1.7 years. Patients rated their most severe symptoms of gastroparesis as nausea (3.7±0.2), early satiety (3.7±0.2), and postprandial fullness (3.8±0.2). Patients with T1DM had greater gastric retention (41±4 vs 23±4% retention at 4 hrs; p<0.05), greater HgbA1c (8.4±1.7 vs 6.3±0.9; p=0.06), and greater vomiting severity (2.7±0.4 vs 0.9±0.6; p=0.03) than patients with T2DM. The majority of diabetic subjects identified that since their diagnosis of gastroparesis, their diabetes was more difficult to control (23 of 33 patients) and that extra time and effort for care of their diabetes was required (22 of 33). In contrast to T2DM, patients with T1DM expressed that since developing gastroparesis, their blood sugars have been higher (0.7±0.3 vs 0.0±0.5; p=0.20), have had more frequent episodes of hypoglycemia (0.6±0.2 vs -0.6±0.4; p<0.01), and found their gastroparetic symptoms worsened with if blood sugars were too high (0.8±0.2 vs 0.1±0.5; p=0.10). Few diabetic patients of either group (7 of 33) felt that their gastroparesis symptoms improved if blood sugars were controlled. Conclusions: Gastroparesis has a significant impact on patients' perceived ability to self-manage and control their diabetes. T1DM patients, in particular, associate their gastroparesis with episodes of hyper- and hypo-glycemia, and find their gastroparetic symptoms worsen with poor control. Future research should focus on strategies to support patient self-management for diabetics with gastroparesis.
S-611
AGA Abstracts
AGA Abstracts
Symptoms Following Meal Ingestion During Gastric Emptying Scintigraphy in Patients With Gastroparesis Akil Hassam, Saraswathi Arasu, Zubair A. Malik, Alan H. Maurer, Henry P. Parkman