- Email: [email protected]
W2069 The Different Faces of Gastroparesis
respiration for an adequate period of time. Therefore, noise contributions to the data were identified excluded from the analysis using Second Order Blind Identification (SOBI). We computed the autoregressive (AR) power spectra from 2-minute segments and identified the dominant frequencies (DF) and percentage of power (PPD) distributed in bradygastric (1-2 cpm), normogastric (2-4 cpm) and tachygastric (4-6 cpm) frequency ranges. We compared DF and PPD of normal controls and diabetic gastroparesis patients. RESULTS. As in the previous hyperglycemia studies, there was a non-significant increase noted in the average dominant frequency recorded from patients (2.8 ± 0.5 cpm) and controls (2.7 ± 0.1 cpm, p=0.4), but the standard deviation of dominant frequencies in patients was notably larger than in controls. Multiple peaks in the AR spectra were observed in patients. There was a borderline significant increase in bradygastric PPD (19.8 ± 6.2%, patients vs. 8.5 ± 2.3%, controls, p=0.07). Gastroparesis patients had smaller normogastric PPD (52.5 ± 10.1%) than controls (78.6 ± 4.2%, p<0.05). The PPD in tachygastric frequencies was significantly larger in patients (27.8 ± 8.0%) than in controls (12.9 ± 2.8%, p<0.05). CONCLUSIONS. Our findings are similar to those in our previous hyperglycemia studies. Although the gastric DF was unchanged, we observed increased variance in DF and a larger percentage of signal power distributed in abnormal frequencies in patients with diabetic gastroparesis. The tendency of signal power to appear in both brady- and tachygastric frequencies therefore suggests uncoupling of the gastric musculature.
W2068 Interstitial Cell of Cajalopathy (ICCpathy) of Human Stomach in Type 2 DM Eun Ran Kim, Kyoung Mee Kim, Sung Kim, Jae Hyung Noh, Hee Jung Son, Jae J Kim, Jong Chul Rhee, Poong-Lyul Rhee Background & Aim: Patients with long-standing diabetes mellitus (DM) commonly suffer from gastropathy. However, the pathophysiology is not fully understood. Interstitial Cells of Cajal (ICC) have been identified as pacemakers and mediators of neurotransmission in GI tract. A deficiency and ultrastructural changes of ICC have been reported in diabetic animal models. The aim of this study was to evaluate ultrastructural changes of ICC in patients with type 2 DM. Methods: Gastric specimens were obtained from 13 diabetic patients (mean age: 65.8 yrs, range: 52-75 yrs) and 6 control subjects (mean age: 60.3yrs, range: 34-72 yrs) with gastric cancer who underwent gastrectomy at Samsung Medical Center between June and November, 2008. All the specimens were taken from the disease-free area. Samples were processed for electron microscopic examination and analyzed. Medical records of diabetic patients which included duration of DM, chronic complication and symptoms were reviewed. . Results: In normal subjects, ICC features were similar to animal models. The nucleus was ovoid and had peripherally condensed heterochromatin. The cytoplasm with numerous lateral branches had abundant mitochondria, intermediate filaments, Golgi apparatus and endoplasmic reticulum. In diabetic patients, several ultrastructural changes of ICC were observed. First, the changes of nucleus was observed. The heterochromatin of the nucleus was decreased and became euchromatic. The wrinking of nuclear envelope which was spreading in whole from part was observed. Some nuclei were shrunken and showed karyorrhectic changes and pyknosis. Second, the changes of cytoplasm was observed. The perinuclear cytoplasm and lateral branches were reduced. Endoplasmic reticulum was markedly dilated and cytoplasmic vacuoles were formed. These changes were more prominent in patients who had long duration of diabetes or autoneuropathy. In some specimens, normal appearing ICCs and degenerated ICCs were coexisted. Conclusion: In diabetes, preapoptotic changes of ICC were observed. We are willing to reffer to these changes as an Interstitial Cell of Cajalopathy(ICCpathy). These results suggest that degeneration of ICCs may be associated with the pathogenesis of diabetic gastroparesis.
W2071 Effect of Acupuncture On Proximal Gastric Motility in Patients with Functional Dyspepsia: A Randomized, Controlled Clinical Study Shunkun Yao, Xiaomei Yao BACKGROUD: Acupuncture has been used to treat GI symptoms in China for thousands of years. It is conceivable that acupuncture may be effective in patients with functional dyspepsia (FD). Dysfunction of the proximal stomach is one of most important pathogenesis in patients with FD. AIM: To investigate the effect of acupuncture on the proximal gastric motility in patients with FD induced by mechanical gastric distention. METHODS: 1. Sixty FD patients (Rome III criteria) were randomly signed to receive either real acupuncture (RA group, 14M/16F, mean 34.0yrs, n = 30) or sham acupuncture (SA group, 13M/17F, mean 32.0yrs, n = 30). 2. The acupoints used were Zusanli (ST 36) and Neiguan (PC 6). RA group were punctured and stimulated with an electric pulse generator by setting the parameters being 10 mA in strength, 500μs in the duration of pulses, 40 Hz in frequency, 12 cpm of pulse trains, and 15 min in the duration of stimulation. SA group didn't puncture. 3. Isovolumetric gastric distention was performed in the all subjects, and RA group performed electrical acupuncture simultaneously. 4. After 8h fasting, a PVC balloon (1L) attached to a catheter (12F, single lumen) was placed orally into the stomach, and gently pulled so as to anchor loosely at the fundus. Gastric volume and pressure were measured by a SVS/ Barostat system (Synectics). When gastric volume was 30ml, the minimal distension pressure (MDP) was figured out. Then initial and maximal tolerable volume, pressure and compliance (the ratio of volume to pressure) were recorded in the two groups. RESULTS: 1. There was no statistical difference in demographics among two groups. 2. MDP had no significant difference between RA group and SA group (5.28±2.62 mmHg vs 4.98±1.87 mmHg, P > 0.05). 3. In RA group, the initial volume and pressure were significantly higher than those in SA group (560.9 ± 119.5 ml vs 352.0 ± 139.3 ml, P < 0.05; 8.06 ± 2.95 mmHg vs 5.40± 2.41 mmHg, P < 0.05). 4. The maximal tolerable volume and pressure were also much higher in RA group relative to SA group (810.7 ± 119.62 ml vs 504.1 ± 159.6 ml, P < 0.05; 13.25 ± 2.23 mmHg vs 9.82 ± 1.9 mmHg, P < 0.05). 5. The compliance in RA group was obviously increased than that of SA group (61.2 ± 18.6 ml/mmHg vs 51.4 ±17.8 ml/mmHg, P < 0.05). CONCLUSION: Acupuncture can improve proximal gastric motility and reduce visceral sensitivity in FD patients, which suggests that Acupuncture is effective in the treatment of patients with FD.
W2069 The Different Faces of Gastroparesis Naeem Raza, Susan Zickmund, Klaus Bielefeldt Postoperative changes, diabetes mellitus (DM-GP), connective tissue disorders (CTD-GP) and idiopathic forms (IP-GP) are among the most common causes of gastroparesis (GP). We hypothesized that impaired gastric function differentially affects patients in these groups. METHODS: Patients with known gastroparesis were asked to complete the Gastroparesis Cardinal Symptom Index (GCSI), Hospital Anxiety and Depression (HAD) Scale, the SF12, and answer 10 open-ended questions about the impact of their disease. RESULTS: A total of 43 patients (34 women; age 42±2 years; symptom duration: 35±5 months; emptying half time: 300±47 min) were enrolled. When asked about the impact of their disease, 20 (47%) patients emphasized the social implications as food intake is tied to many professional and private activities; 10 (23%) complained about severe fatigue and 9 (21%) about emotional effects. Thirteen patients (30%) reported difficulties meeting professional expectations, 8 (18%) had lost their job or quit school, and 8 (18%) were disabled. Twenty-two (51%) patients mentioned more than one dominant symptom with pain (N=19; GSCI: 2.9±0.3), nausea (N=16; GCSI: 3.1±0.2), vomiting (N=12; GSCI: 1.8±0.3) and bloating (N=12; GSCI: 3.0±0.3) being listed most commonly. Twelve (28%) rated dietary changes, 9 (21%) antiemetics and 9 (21%) prokinetics as most helpful in their therapy. Patients with IP-GP were significantly younger (36±4 years vs. DM-GP: 46±3 years; CTD-GP: 58±2 years; P<0.01) and rated pain levels higher compared to patients with CTD-GP (1.3±0.8 vs. 3.3±0.3, respectively; P<0.05). Bivariate analyses demonstrated that bloating, low appetite and nausea significantly correlated with the physical component of the SF12 (PCS). The mental component of the SF12, HAD scores, disease duration and gastric emptying delay did not correlate with GCSI scores. Based on multiple linear regression analyses combining depression, bloating and poor appetite best predicted the PCS score. CONCLUSIONS: Gastroparesis significantly impairs the quality of life with a high number of patients not being able to meet social role expectations. Pain is a prominent symptom that differentially affects patient subgroups with gastroparesis. In addition to physical symptoms, depression significantly contributes to the overall impact of the disease.
W2072 Comparison of the SmartPill pH.P Capsule© to Radioisotope Study for Measurement of Gastric Emptying (GE) Time and Oro-Colonic (OC) Transit in Short Bowel Patients Antwan Atia, William G. Spies, Alan L. Buchman Introduction: Measurement of GE time and oro-colonic transit may be useful measures in the efficacy assessment of anti-motility agents in patients with SBS. Methods: We studied 6 patients (3 M, 3F) aged 29-67 yrs with SBS, all of whom had colonic-jejunal anastomosis, and 4 of which required parental nutrition. Mean residual small bowel length was 50.3±36.5 cm and mean residual colon length was 39.3±5.1cm. Each subject had 2 simultaneous SmartPill and Tc99 GE studies, separated by 2 wks. Subjects received a pectin supplement (6 g tid) in addition to usual daily meals in the intervening time. Each subject ingested a SmartPill© (SmartPill Corp, Buffalo) following an 8 hr overnight fast. The SmartPill was 26 x 13 mm in size and contained pH, temperature, and pressure probes as well as a wireless transmitter. An ambulatory data recorder captured data over a 24 hr period. Patients had a simultaneous radioisotope GE and OC transit study. 2 eggs were each injected with 1 mCi 99mTc sulfur-colloid, cooked, and scrambled. Each subject ingested an egg sandwich consisting of 2 scrambled eggs with 2 pieces of toast. Dynamic images were then obtained using 300 second frames for 24 frames with a matrix size of 128 × 128. Gastric emptying for the SmartPill was determined by an abrupt rise in pH of at least 3 units; this indicated the capsule had passed into the alkaline duodenum. Appearance in the colon was determined by an pressure increase by more than 65 mmHg accompanied by a 0.3 unit decrease in pH. Radiosotopic GE time was defined as the time for 50% of the tracer to leave the stomach (t1/2), and oro-colonic bowel transit time was defined as the time from meal ingestion to the time the first tracer is identified in the colon. Results: The mean GE time and the OC transit time when measured by the Smartpill© were 10.33±8.23 min and 13.02± 9.71 min, respectively. Mean t1/2 GE and the OC transit times were 80.6±26.29 min and 71.4±40.43 min, respectively. The Pearson correlations between SmartPill© GE and t1/2 (anterior view, Geo mean, respectively) were r= -0.213 and r= -0.164. The Pearson correlation between SmartPill© and radioisotopic OC transit times was r=-0.261. Conclusion: There was no correlation between Smartpill© and radioisotope measurements of GE or small bowel transit
W2070 Biomagnetic Signatures of Diabetic Gastroparesis Leonard A. Bradshaw, Chike B. Obioha, Eric Chung, Jonathan Erickson, William O. Richards INTRODUCTION. In previous studies, we demonstrated that the magnetogastrogram (MGG) reflects changes in the gastric slow wave (SW) due to glucagon-induced hyperglycemia. Our hypothesis was that similar effects would be observed in patients with diabetic gastroparesis. METHODS. Patients with a previous diagnosis of diabetic gastroparesis (N = 7) and healthy controls (N = 7) were fasted for 8 hours and asked to lie quietly underneath a Superconducting QUantum Interference Device (SQUID) biomagnetometer. We obtained MGG recordings for a baseline of 20 minutes after which subjects were fed a standard 300 kCal turkey sandwich meal and postprandial recordings obtained for a period of one hour. We selected pre- and postprandial data segments in which no ambient magnetic noise due to motion artifacts or moving metallic objects was evident. In previous studies, we have analyzed respiration-free data segments, but diabetic gastroparetic patients found it difficult to suspend
A-785
AGA Abstracts
AGA Abstracts
during 6 weeks of two-channel gastric pacing. Conclusions: Two-channel gastri pacing is able to decrease the LF/HF ratio, indicating a significant increase in vagal activity during gastric pacing. These findings could help explain the symptomatic improvement resulting from two-channel gastric pacing in these diabetics with refractory gastroparesis.
W2068 Interstitial Cell of Cajalopathy (ICCpathy) of Human Stomach in Type 2 DM Eun Ran Kim, Kyoung Mee Kim, Sung Kim, Jae Hyung Noh, Hee Jung Son, Jae J Kim, Jong Chul Rhee, Poong-Lyul Rhee Background & Aim: Patients with long-standing diabetes mellitus (DM) commonly suffer from gastropathy. However, the pathophysiology is not fully understood. Interstitial Cells of Cajal (ICC) have been identified as pacemakers and mediators of neurotransmission in GI tract. A deficiency and ultrastructural changes of ICC have been reported in diabetic animal models. The aim of this study was to evaluate ultrastructural changes of ICC in patients with type 2 DM. Methods: Gastric specimens were obtained from 13 diabetic patients (mean age: 65.8 yrs, range: 52-75 yrs) and 6 control subjects (mean age: 60.3yrs, range: 34-72 yrs) with gastric cancer who underwent gastrectomy at Samsung Medical Center between June and November, 2008. All the specimens were taken from the disease-free area. Samples were processed for electron microscopic examination and analyzed. Medical records of diabetic patients which included duration of DM, chronic complication and symptoms were reviewed. . Results: In normal subjects, ICC features were similar to animal models. The nucleus was ovoid and had peripherally condensed heterochromatin. The cytoplasm with numerous lateral branches had abundant mitochondria, intermediate filaments, Golgi apparatus and endoplasmic reticulum. In diabetic patients, several ultrastructural changes of ICC were observed. First, the changes of nucleus was observed. The heterochromatin of the nucleus was decreased and became euchromatic. The wrinking of nuclear envelope which was spreading in whole from part was observed. Some nuclei were shrunken and showed karyorrhectic changes and pyknosis. Second, the changes of cytoplasm was observed. The perinuclear cytoplasm and lateral branches were reduced. Endoplasmic reticulum was markedly dilated and cytoplasmic vacuoles were formed. These changes were more prominent in patients who had long duration of diabetes or autoneuropathy. In some specimens, normal appearing ICCs and degenerated ICCs were coexisted. Conclusion: In diabetes, preapoptotic changes of ICC were observed. We are willing to reffer to these changes as an Interstitial Cell of Cajalopathy(ICCpathy). These results suggest that degeneration of ICCs may be associated with the pathogenesis of diabetic gastroparesis.
W2071 Effect of Acupuncture On Proximal Gastric Motility in Patients with Functional Dyspepsia: A Randomized, Controlled Clinical Study Shunkun Yao, Xiaomei Yao BACKGROUD: Acupuncture has been used to treat GI symptoms in China for thousands of years. It is conceivable that acupuncture may be effective in patients with functional dyspepsia (FD). Dysfunction of the proximal stomach is one of most important pathogenesis in patients with FD. AIM: To investigate the effect of acupuncture on the proximal gastric motility in patients with FD induced by mechanical gastric distention. METHODS: 1. Sixty FD patients (Rome III criteria) were randomly signed to receive either real acupuncture (RA group, 14M/16F, mean 34.0yrs, n = 30) or sham acupuncture (SA group, 13M/17F, mean 32.0yrs, n = 30). 2. The acupoints used were Zusanli (ST 36) and Neiguan (PC 6). RA group were punctured and stimulated with an electric pulse generator by setting the parameters being 10 mA in strength, 500μs in the duration of pulses, 40 Hz in frequency, 12 cpm of pulse trains, and 15 min in the duration of stimulation. SA group didn't puncture. 3. Isovolumetric gastric distention was performed in the all subjects, and RA group performed electrical acupuncture simultaneously. 4. After 8h fasting, a PVC balloon (1L) attached to a catheter (12F, single lumen) was placed orally into the stomach, and gently pulled so as to anchor loosely at the fundus. Gastric volume and pressure were measured by a SVS/ Barostat system (Synectics). When gastric volume was 30ml, the minimal distension pressure (MDP) was figured out. Then initial and maximal tolerable volume, pressure and compliance (the ratio of volume to pressure) were recorded in the two groups. RESULTS: 1. There was no statistical difference in demographics among two groups. 2. MDP had no significant difference between RA group and SA group (5.28±2.62 mmHg vs 4.98±1.87 mmHg, P > 0.05). 3. In RA group, the initial volume and pressure were significantly higher than those in SA group (560.9 ± 119.5 ml vs 352.0 ± 139.3 ml, P < 0.05; 8.06 ± 2.95 mmHg vs 5.40± 2.41 mmHg, P < 0.05). 4. The maximal tolerable volume and pressure were also much higher in RA group relative to SA group (810.7 ± 119.62 ml vs 504.1 ± 159.6 ml, P < 0.05; 13.25 ± 2.23 mmHg vs 9.82 ± 1.9 mmHg, P < 0.05). 5. The compliance in RA group was obviously increased than that of SA group (61.2 ± 18.6 ml/mmHg vs 51.4 ±17.8 ml/mmHg, P < 0.05). CONCLUSION: Acupuncture can improve proximal gastric motility and reduce visceral sensitivity in FD patients, which suggests that Acupuncture is effective in the treatment of patients with FD.
W2069 The Different Faces of Gastroparesis Naeem Raza, Susan Zickmund, Klaus Bielefeldt Postoperative changes, diabetes mellitus (DM-GP), connective tissue disorders (CTD-GP) and idiopathic forms (IP-GP) are among the most common causes of gastroparesis (GP). We hypothesized that impaired gastric function differentially affects patients in these groups. METHODS: Patients with known gastroparesis were asked to complete the Gastroparesis Cardinal Symptom Index (GCSI), Hospital Anxiety and Depression (HAD) Scale, the SF12, and answer 10 open-ended questions about the impact of their disease. RESULTS: A total of 43 patients (34 women; age 42±2 years; symptom duration: 35±5 months; emptying half time: 300±47 min) were enrolled. When asked about the impact of their disease, 20 (47%) patients emphasized the social implications as food intake is tied to many professional and private activities; 10 (23%) complained about severe fatigue and 9 (21%) about emotional effects. Thirteen patients (30%) reported difficulties meeting professional expectations, 8 (18%) had lost their job or quit school, and 8 (18%) were disabled. Twenty-two (51%) patients mentioned more than one dominant symptom with pain (N=19; GSCI: 2.9±0.3), nausea (N=16; GCSI: 3.1±0.2), vomiting (N=12; GSCI: 1.8±0.3) and bloating (N=12; GSCI: 3.0±0.3) being listed most commonly. Twelve (28%) rated dietary changes, 9 (21%) antiemetics and 9 (21%) prokinetics as most helpful in their therapy. Patients with IP-GP were significantly younger (36±4 years vs. DM-GP: 46±3 years; CTD-GP: 58±2 years; P<0.01) and rated pain levels higher compared to patients with CTD-GP (1.3±0.8 vs. 3.3±0.3, respectively; P<0.05). Bivariate analyses demonstrated that bloating, low appetite and nausea significantly correlated with the physical component of the SF12 (PCS). The mental component of the SF12, HAD scores, disease duration and gastric emptying delay did not correlate with GCSI scores. Based on multiple linear regression analyses combining depression, bloating and poor appetite best predicted the PCS score. CONCLUSIONS: Gastroparesis significantly impairs the quality of life with a high number of patients not being able to meet social role expectations. Pain is a prominent symptom that differentially affects patient subgroups with gastroparesis. In addition to physical symptoms, depression significantly contributes to the overall impact of the disease.
W2072 Comparison of the SmartPill pH.P Capsule© to Radioisotope Study for Measurement of Gastric Emptying (GE) Time and Oro-Colonic (OC) Transit in Short Bowel Patients Antwan Atia, William G. Spies, Alan L. Buchman Introduction: Measurement of GE time and oro-colonic transit may be useful measures in the efficacy assessment of anti-motility agents in patients with SBS. Methods: We studied 6 patients (3 M, 3F) aged 29-67 yrs with SBS, all of whom had colonic-jejunal anastomosis, and 4 of which required parental nutrition. Mean residual small bowel length was 50.3±36.5 cm and mean residual colon length was 39.3±5.1cm. Each subject had 2 simultaneous SmartPill and Tc99 GE studies, separated by 2 wks. Subjects received a pectin supplement (6 g tid) in addition to usual daily meals in the intervening time. Each subject ingested a SmartPill© (SmartPill Corp, Buffalo) following an 8 hr overnight fast. The SmartPill was 26 x 13 mm in size and contained pH, temperature, and pressure probes as well as a wireless transmitter. An ambulatory data recorder captured data over a 24 hr period. Patients had a simultaneous radioisotope GE and OC transit study. 2 eggs were each injected with 1 mCi 99mTc sulfur-colloid, cooked, and scrambled. Each subject ingested an egg sandwich consisting of 2 scrambled eggs with 2 pieces of toast. Dynamic images were then obtained using 300 second frames for 24 frames with a matrix size of 128 × 128. Gastric emptying for the SmartPill was determined by an abrupt rise in pH of at least 3 units; this indicated the capsule had passed into the alkaline duodenum. Appearance in the colon was determined by an pressure increase by more than 65 mmHg accompanied by a 0.3 unit decrease in pH. Radiosotopic GE time was defined as the time for 50% of the tracer to leave the stomach (t1/2), and oro-colonic bowel transit time was defined as the time from meal ingestion to the time the first tracer is identified in the colon. Results: The mean GE time and the OC transit time when measured by the Smartpill© were 10.33±8.23 min and 13.02± 9.71 min, respectively. Mean t1/2 GE and the OC transit times were 80.6±26.29 min and 71.4±40.43 min, respectively. The Pearson correlations between SmartPill© GE and t1/2 (anterior view, Geo mean, respectively) were r= -0.213 and r= -0.164. The Pearson correlation between SmartPill© and radioisotopic OC transit times was r=-0.261. Conclusion: There was no correlation between Smartpill© and radioisotope measurements of GE or small bowel transit
W2070 Biomagnetic Signatures of Diabetic Gastroparesis Leonard A. Bradshaw, Chike B. Obioha, Eric Chung, Jonathan Erickson, William O. Richards INTRODUCTION. In previous studies, we demonstrated that the magnetogastrogram (MGG) reflects changes in the gastric slow wave (SW) due to glucagon-induced hyperglycemia. Our hypothesis was that similar effects would be observed in patients with diabetic gastroparesis. METHODS. Patients with a previous diagnosis of diabetic gastroparesis (N = 7) and healthy controls (N = 7) were fasted for 8 hours and asked to lie quietly underneath a Superconducting QUantum Interference Device (SQUID) biomagnetometer. We obtained MGG recordings for a baseline of 20 minutes after which subjects were fed a standard 300 kCal turkey sandwich meal and postprandial recordings obtained for a period of one hour. We selected pre- and postprandial data segments in which no ambient magnetic noise due to motion artifacts or moving metallic objects was evident. In previous studies, we have analyzed respiration-free data segments, but diabetic gastroparetic patients found it difficult to suspend
A-785
AGA Abstracts
AGA Abstracts
during 6 weeks of two-channel gastric pacing. Conclusions: Two-channel gastri pacing is able to decrease the LF/HF ratio, indicating a significant increase in vagal activity during gastric pacing. These findings could help explain the symptomatic improvement resulting from two-channel gastric pacing in these diabetics with refractory gastroparesis.