ABSTRACT: Constipation affects up to 28% of Americans in 4 pathophysiologic patterns: slow transit constipation, dyssynergic defecation, a combination of both, and normal colon transit with normal pelvic floor function. Constipation may be a part of a generalized gastrointestinal (GI) tract transit disorder. The purposes of this study were to determine the percentage of constipated patients with the different pathophysiologic subtypes and and to evaluate what percentage of constipated patients has a diffuse GI tract transit disorder.
This was a retrospective analysis of 212 patients who underwent anorectal manometry for intractable constipation. Results of anorectal manometry, electromyography, balloon expulsion testing, defecography, and whole-gut transit scintigraphy were reviewed.
Of 212 patients included in the analysis, 91 (42%) had slow transit constipation, 25 (12%) had dyssynergic defecation, 53 (25%) had both, and 43 (20%) had neither. Of patients (91) with slow transit constipation alone, 31 (34%) had delayed gastric emptying, 9 (10%) had delayed small bowel transit, 7 (8%) had a delay in both, and 41 (48%) had normal upper GI tract transit. A similar distribution of upper GI tract transit disorders was observed for patients with dyssynergic defecation, slow transit constipation and dyssynergic defecation, and normal colon transit with normal pelvic floor function.
Patients with chronic idiopathic constipation have a range of colonic motor disorders. The majority (80%) had slow transit constipation, dyssynergic defecation, or a combination of slow transit constipation and dyssynergic defecation. In addition, many patients (51%) with chronic idiopathic constipation have a concurrent upper GI tract transit disorder.
Journal of clinical gastroenterology 02/2012; 46(2):150-4. · 2.21 Impact Factor
ABSTRACT: Delayed gastric emptying can alter glucose levels in diabetic patients; hyperglycemia can delay gastric emptying. Continuous glucose monitoring (CGM) may be useful to assess the relationship between gastric emptying and blood glucose levels.
The aims of this study were to compare the postprandial blood glucose profile of patients with type 2 diabetes mellitus (T2DM) with and without gastroparesis, normal subjects, and patients with idiopathic gastroparesis (IG), and also to determine the effect of different meal compositions on glucose regulation in T2DM and normals.
Seven patients with IG, seven T2DM with gastroparesis, ten non-gastroparetic T2DM, and ten normal subjects underwent CGM during a low fat (Eggbeaters) meal. Glucose profiles were also studied in T2DM and normal subjects after high fat, high fiber, spicy, and Ensure liquid nutrient meals.
After the Eggbeaters meal, the glucose profile of IGs and normals were similar. Diabetic patients with gastroparesis had similar peak postprandial blood glucose to nongastroparetic diabetics (231 ± 26 vs. 232 ± 18 mg/dl), but had a higher postprandial blood glucose at the end of the 4 h study (187 ± 26 mg/dl vs. 97 ± 10; P = 0.01). In contrast to normals, non-gastroparetic diabetics had higher mean postprandial blood sugar after the Eggbeaters meal (173 ± 5 mg/dl) compared to high fat (157 ± 3; P = 0.002), spicy (133 ± 2; P < 0.001) and Ensure meals (152 ± 1; P < 0.001).
Blood glucose monitoring provides insight to the presence of gastroparesis in diabetic patients: diabetic gastroparetics had prolonged postprandial hyperglycemic profile as compared to non-gastroparetic diabetics. Of the meals tested, the low fat (Eggbeaters) meal was associated with the highest mean postprandial glucose in diabetics.
Digestive Diseases and Sciences 07/2011; 56(9):2646-55. · 2.12 Impact Factor
The Israel Medical Association journal: IMAJ 01/2011; 13(1):66. · 1.02 Impact Factor
ABSTRACT: The clinical course of patients with gastroparesis is characterized by symptomatic exacerbations often necessitating hospitalization.
To investigate precipitating factors leading to hospitalization for exacerbation of symptoms in patients with gastroparesis.
This was a retrospective review of 103 admissions (63 patients) for gastroparesis exacerbation.
Etiologic categories for gastroparetic patients were diabetic (43%), idiopathic (39%), and post surgical (8%). Poor glycemic control was present in 36%, infection in 19% (12 urinary tract infections and two bacteremia), and noncompliance with or intolerance of, medications in six and 5% of patients, respectively. Fasting morning cortisol concentrations were \3 mcg/dl in 9%. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were seen in 34 of 65 (52%) and 11 of 50 patients (22%), respectively. No identifiable infection was found in 74 and 45% of patients with elevated ESR and elevated CRP, respectively. ESR and CRP were higher when patients were symptomatic necessitating hospitalization (26.2 +/- 6.6 mm/h and 1.6 +/- 1.0 mg/l) compared with when they were seen in outpatient follow-up and less symptomatic (10.3 +/- 2.9 mm/h and 0.3 +/- 0.1 mg/l; P = 0.0001 and P = 0.211, respectively).
Poor glycemic control, infection, noncompliance with/intolerance of medications, and, perhaps, adrenal insufficiency were contributory factors leading to hospitalizations of gastroparetic patients. Hospitalized patients with gastroparesis exacerbations had elevated ESR and CRP levels. Although many patients with elevated inflammatory markers had evidence of infection, some did not. Assessment of inflammatory markers may help indicate those gastroparetic patients in whom a search for infection should be undertaken.
Digestive Diseases and Sciences 09/2009; 54(11):2404-9. · 2.12 Impact Factor
ABSTRACT: Tumor burden is difficult to estimate by endoscopy and conventional EUS.
The purpose of this study was to determine the accuracy and the reliability of a new 3-dimensional (3D) EUS system in a pseudotumor model (Olympus EUS EXERA EU-M60).
A pseudotumor model was developed in a porcine stomach. Pseudotumors were created by injecting various volumes of US gel (0.3, 0.5, 0.7, and 1 mL) into porcine stomach specimens, and then the volume was measured in vitro. Two investigators made volume measurements by outlining the cross-sectional area of the pseudotumor at different radial planes. The instrument then automatically calculated the volume based on the outlined cross-sectional areas. The measured volume was compared with the actual volume of the pseudotumor by using a Bland-Altman analysis. Every second, third, fourth, fifth, sixth, and tenth image was measured to calculate the tumor volume and to determine the optimum number of images required for accurate volume determination. Inter- and intraobserver variability, percentage error, Bland-Altman analysis, analysis of variance (ANOVA), and kappa statistic were performed.
This study was performed in an in vitro animal model.
There were no patients involved in this study.
Accuracy and reliability of pseudotumor volume measurement.
When averaging across all measurements, the overall average mean error was 3.25%. The overall inter-rater reliability as measured by intraclass correlation coefficient was 0.78. The overall intra-rater reliability as measured by intraclass correlation coefficient was 0.99. Bland-Altman analysis and ANOVA showed similar low variability for measured volumes based on image frequencies for volume calculations between every other and every sixth image but greater variability for measured volumes based on every tenth image. Larger pseudotumors were measured with a slight decrease in mean percentage error. The kappa statistic for interobserver variability was .61, which demonstrated substantial agreement among observers.
The major limitation of this technology is the penetration of the US beam to evaluate large tumors, because the US transducer is high frequency (20 MHz) and, therefore, has a limited penetration.
In conclusion, the new Olympus EUS EXERA EU-M60 3D US probe allowed for accurate volume measurements of small pseudotumors in porcine stomach model in vitro. There was substantial evaluator agreement, with a low interobserver variability. Larger pseudotumors were measured with a slightly lower percentage error than smaller pseudotumors. Volumes measured with a greater number of radial images were measured slightly more accurately. We plan to test this device in patients with GI tumors in the near future.
Gastrointestinal Endoscopy 11/2006; 64(4):635-40. · 4.88 Impact Factor
ABSTRACT: The use of high-frequency ultrasound transducers in the gastrointestinal tract (GI) has already yielded remarkable findings concerning the anatomy, physiology and pathophysiology of the GI tract and of various motility disorders. These transducers have made completely invisible portions of the GI tract (the longitudinal smooth muscle, muscles of the upper esophageal sphincter, components of the gastroesophageal junction high-pressure zone, and the muscle of the anal sphincter complex) accessible to investigation. Use of simultaneous ultrasound and manometry has allowed the exploration of the normal physiology of peristaltic contraction. The components of the high-pressure zone of the distal and proximal esophagus have been isolated and the movement of these components has been studied individually and as a group. Various esophageal motility disorders have been investigated including achalasia, scleroderma, Barrett's esophagus and diffuse esophageal spasm. The possible etiology of the symptoms of esophageal chest pain and heartburn (sustained esophageal contractions of the longitudinal smooth muscle), have been studied. The possible underlying pathophysiology of GERD (the missing gastric clasp and sling fiber pressure profile) has been explored. Three-dimensional high-frequency ultrasound imaging has allowed the peristaltic contraction sequence to be viewed in a completely new and unique manner. The biomechanics of both esophageal contraction and the gastroesophageal junction high-pressure zone have been investigated and the mechanical advantage of esophageal shorting has been studied. The mechanism of action of standard surgical and newer endoscopic therapies for GERD has been defined. Future applications of this technology are limited only by our imagination.
Digestive Diseases 02/2006; 24(3-4):319-41. · 2.37 Impact Factor