2021 TDDW
Symposium (V) UPDATES IN THE TREATMENT OF FUNCTIONAL GI DISORDER
GUT DYSFUNCTION IN DIABETES: DIAGNOSIS AND TREATMENT Ping-Huei Tseng Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Diabetes mellitus has been associated a myriad of upper and lower gastrointestinal complications, including reflux esophagitis, gastroparesis, diarrhea and constipation, all of which may affect the quality of life and glycemic control. The pathogenesis of gastrointestinal complications in diabetic patients is multi-factorial and has been mainly attributed to autonomic neuropathy, which can impair both gastric acid secretion and gastrointestinal motility. Various gut hormones, including ghrelin, pancreatic polypeptide-fold peptides, amylin and glucagon-like peptide 1, also play crucial roles in regulation of food intake, gastrointestinal motility, energy balance, and body weight by working with the complex neural circuits in the brainstem, hypothalamus, and higher cortical centers. Normal gastric emptying is the result of coordinated activity in the proximal and distal regions of the stomach, and may be affected by several factors, such as the volume, composition and total calories of the ingested food, various neurohormonal factors and personal factors, such as pregnancy, anxiety and aging. Delayed or rapid gastric emptying has been associated with a number of gastrointestinal disorders, such as diabetic gastroparesis, functional dyspepsia, gastroesophageal reflux disease and dumping syndrome. Among them, diabetic gastroparesis is the most recognized and is characterized by the delayed gastric emptying, accompanied by severe nausea, vomiting and abdominal fullness, in the absence of mechanical obstruction of the stomach. Since delayed and rapid gastric emptying may cause similar gastrointestinal symptoms, such as nausea, vomiting and bloating, and therefore the importance of determining the rate of gastric emptying to guide the treatment choice has been
stressed. Currently, gastric emptying scintigraphy with solid test meals remains the gold standard to assess delayed gastric emptying. Nevertheless, methodologies related to test meal and imaging protocols in determining gastric emptying time differ between institutions and regions. Other novel tests, including 13C-octanoate breath testing and wireless motility capsule, have been applied in several recent studies to determine gastric emptying, and each has its own advantages and limitations. Glycemic control, dietary measures, such as low fiber, low fat food, prokinetic drugs (e.g., domperidone, metoclopramide and erythromycin) and antiemetic drugs (e.g, phenothiazines, diphenhydramine) are generally effective for symptomatic relief in the majority of gastroparesis patients. When medical treatments become ineffective over time and associated with adverse events and tachyphylaxia, various interventional therapies may be initiated. The surgical laparoscopic pyloroplasty appeared efficacious but remained technically complicated and risky. Treatment with gastric electrical stimulation (GES) is reversible and may be a less invasive option compared to surgical intervention for the treatment of patients with chronic, drug-refractory nausea and vomiting secondary to gastroparesis. It has been proposed that GES could override the abnormal rhythms, stimulate gastric emptying and eliminate symptoms of gastroparesis. Nevertheless, the efficacy of GES remains unsatisfactory at present. Endoscopic approaches include intra-pyloric injection of botulinium toxin, stenting, and pyloric dilatation. Recently, gastric peroral endoscopic pyloromyotomy (G-POEM) has emerging as minimally invasive therapy for gastroparesis with a promising early and mid-term efficacy.
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