Lucilene Rosa-e-Silva

Treatment of diabetic gastroparesis with oral clonidine

Background/Aims: Clonidine, a specific alpha‐2‐adrenergic receptor agonist, has been suggested to improve symptoms of gastroparesis in diabetics with diarrhoea. The aim of this study was to investigate the effects of clonidine on gastric emptying and symptoms suggestive of gastroparesis in patients with long‐standing diabetes mellitus and evidence of autonomic neuropathy.

Abnormal Intragastric Distribution of a Liquid Nutrient Meal in Patients with Diabetes Mellitus

Disordered gastric motility and emptying arewell known complications of diabetes mellitus (DM), butthe pattern of intragastric distribution of food has notbeen extensively studied in diabetics. We examined the partition of a liquid nutrient meal betweenthe proximal and distal stomach and the relationshipsbetween intragastric distribution of food and gastricemptying (GE) and the symptoms in DM patients with and without autonomic neuropathy (AN).Fourteen healthy volunteers and 20 DM patients (13 withAN; 9 with dyspepsia symptoms) ingested a liquidnutrient meal (250 ml; 437 kcal) labeled with[99mTc]phytate. Anterior and posterior serial images of thestomach were taken for 90 min with a gamma camera.Regions of interest for the proximal and the distalhalves of the stomach and for the total gastric areawere defined. Counts from each region along timeallowed estimation of GE and the proportion of activityretained in the proximal stomach after meal ingestion(initial) and throughout GE (mean). GE half-times in controls (median; range: 66 min; 29-90 min)were not significantly different from diabetics (76 min;5->150 min, P > 0.10), but abnormal GE was foundin 11 DM patients (seven delayed and four rapid). In DM patients, initial retention inthe proximal stomach (42%; 16-79% ) was significantlylower (P < 0.02) than in controls (55%; 44-71%). Meanretention in the proximal stomach throughout emptying also was significantly lower (P <0.05) in DM patients (43%; 18-58%) than in controls(51%; 32-69%). There were no differences betweensubgroups of patients with normal, delayed, or rapid gastric emptying regarding mean meal retentionin the proximal stomach. Patients with evidence of AN orwith dyspepsia symptoms had significantly decreasedretention of food in the proximal stomach throughout gastric emptying. We concluded that patientswith diabetes mellitus have abnormally decreasedretention of gastric contents in the proximal stomachafter a liquid meal, which seems to be related to the occurrence of autonomic neuropathy anddyspepsia symptoms, but not to disordered gastricemptying.

Rapid distal small bowel transit associated with sympathetic denervation in type I diabetes mellitus.

BACKGROUND: The pattern of progression of a meal from the stomach to the caecum in diabetes mellitus is controversial and the differential roles of transit through the jejunum and the ileum have not been investigated in diabetes. AIMS: To determine gastric emptying and transit rates through proximal and distal regions of the small bowel in type I diabetic patients. SUBJECTS: The study included six diabetic patients with evidence of autonomic neuropathy (DM-AN group), 11 diabetics without autonomic dysfunction (DM group), and 15 control volunteers. METHODS: Gastric emptying and small bowel transit of a liquid meal were evaluated scintigraphically in these subjects. Transit through regions of interest corresponding to the proximal and distal small intestine up to the caecum was determined and correlated with gastric emptying rates, cardiovascular measurements of autonomic function, and the occurrence of diarrhoea. RESULTS: Gastric emptying and transit through the proximal small bowel were similar in the three groups. The meal arrived to the caecum significantly earlier in DM-AN patients (median; range: 55 min; 22-->180 min) than in the DM group (100 min; 44-->180 min, p < 0.05) or in controls (120 min; 80-->180 min, p < 0.02). Accumulation of chyme in the distal small bowel was decreased in DM-AN patients, who showed values for peak activity (30%; 10-55%) significantly lower than in the DM group (49%; 25-77%, p = 0.02) and controls (50%; 30-81%, p = 0.02). In DM patients (n = 17), the time of meal arrival to the caecum was significantly correlated with both orthostatic hypotension (coefficient of contingency, C = 0.53, p < 0.01) and diarrhoea (C = 0.47, p < 0.05), but not with gastric emptying rates. CONCLUSIONS: Patients with type I diabetes mellitus and sympathetic denervation have abnormally rapid transit of a liquid meal through the distal small bowel, which may play a part in diarrhoea production.

Freqüência de sintomas digestivos em pacientes brasileiros com Diabetes Mellitus

PURPOSE: To determine the frequencies of digestive symptoms in an unselected sample of Brazilian diabetics, in comparison to those verified in the general population. METHODS: The frequencies of 13 digestive symptoms were determined in 153 type 1 and type 2 diabetics and in 50 apparently healthy controls, utilizing a structured, standardized questionnaire. RESULTS: The percentage of diabetics with at least one symptom was significantly higher than in controls (70% vs 36%, p = 0.01). Higher frequencies of upper digestive symptoms, such as postprandial epigastric fullness (30% vs 35%), heartburn (30% vs 34%), as well as constipation (17% vs 12%) were observed in both groups. Nevertheless, only the prevalence of dysphagia (13% vs 2%) was significantly increased (p = 0.02) in diabetics. CONCLUSION: These findings indicate that gastrointestinal symptoms are common in diabetics, but this seems also to be the case in the general population, with the exception of dysphagia. The frequencies of symptoms observed in Brazil were similar to those reported in studies from the North Hemisphere, a finding that does not support the hypothesis that external factors may influence the prevalence of gastrointestinal symptoms in diabetics.PURPOSE To determine the frequencies of digestive symptoms in an unselected sample of Brazilian diabetics, in comparison to those verified in the general population. METHODS The frequencies of 13 digestive symptoms were determined in 153 type 1 and type 2 diabetics and in 50 apparently healthy controls, utilizing a structured, standardized questionnaire. RESULTS The percentage of diabetics with at least one symptom was significantly higher than in controls (70% vs 36%, p = 0.01). Higher frequencies of upper digestive symptoms, such as postprandial epigastric fullness (30% vs 35%), heartburn (30% vs 34%), as well as constipation (17% vs 12%) were observed in both groups. Nevertheless, only the prevalence of dysphagia (13% vs 2%) was significantly increased (p = 0.02) in diabetics. CONCLUSION These findings indicate that gastrointestinal symptoms are common in diabetics, but this seems also to be the case in the general population, with the exception of dysphagia. The frequencies of symptoms observed in Brazil were similar to those reported in studies from the North Hemisphere, a finding that does not support the hypothesis that external factors may influence the prevalence of gastrointestinal symptoms in diabetics.

Factors associated with abnormal gastric emptying in alcohol-related chronic pancreatitis

Background Patients with alcohol-related chronic pancreatitis (ARCP) may present with abnormal gastric emptying (GE), which has been ascribed mainly to nutrient maldigestion. Nevertheless, many patients also have diabetes with autonomic dysfunction and malnutrition and the role of these factors on abnormal GE has not been investigated. Goals To determine the influences of malabsorption, diabetes, malnutrition, and autonomic dysfunction on GE abnormalities in patients with ARCP. Study Forty ARCP outpatients and 18 healthy controls were studied. GE was measured by scintigraphy after a standard, liquid, nutrient meal labeled with 99mTechnetium-phytate. Autonomic function was evaluated by cardiovascular tests. The influence of each factor on abnormal GE was assessed by Bayesian multiple regression analysis. Results In the ARCP group, GE was abnormal in 19 patients (47.5%), who showed either accelerated (N=12) or delayed emptying (N=7). Diabetes was highly prevalent (P<0.01) in ARCP patients with either rapid or delayed GE (18/19). Multiple regression analysis showed that not only diabetes, but also autonomic dysfunction has significant effects on abnormal GE, whereas malabsorption and malnutrition seemed not to be associated to abnormal emptying. Conclusions A substantial proportion of patients with ARCP may have abnormal GE. Either delayed or accelerated GE seem to be related to underlying diabetes mellitus and autonomic neuropathy rather than to nutrient malabsorption and malnutrition.

Autonomic nervous function in alcohol-related chronic pancreatitis.

Patients with alcohol-related chronic pancreatitis (ARCP) often have peripheral neuropathy, but no data on the occurrence of autonomic neuropathy (AN) are available for this condition. To assess the autonomic function and the significance of its abnormalities for the prognosis of ARCP, 18 patients with ARCP and associated diabetes mellitus (P-DM group), 10 with ARCP without evidence of diabetes mellitus (P group), 17 patients with insulin-dependent diabetes mellitus (IDDM group), and 18 healthy controls answered a structured questionnaire and underwent three standardized cardiovascular (CV) tests that yielded six different parameters for autonomic nerve function. Patients with at least one symptom plus two abnormal results on CV tests were regarded as having AN. ARCP patients were followed up for 48 months and mortality rates were recorded. The proportions of patients with AN were 66.6% in the P-DM group, 30.0% in the P group, and 29.4% in IDDM patients. Seven of 15 ARCP patients with AN died during follow-up, compared with one of 13 of those without AN (p < 0.037). In conclusion, AN is commonly found in ARCP patients and carries an ominous prognosis.

Determinants of Accelerated Small Intestinal Transit in Alcohol-Related Chronic Pancreatitis

Patients with chronic pancreatitis may have abnormal gastrointestinal transit, but the factors underlying these abnormalities are poorly understood. Gastrointestinal transit was assessed, in 40 male outpatients with alcohol-related chronic pancreatitis and 18 controls, by scintigraphy after a liquid meal labeled with 99mtechnetium-phytate. Blood and urinary glucose, fecal fat excretion, nutritional status, and cardiovascular autonomic function were determined in all patients. The influence of diabetes mellitus, malabsorption, malnutrition, and autonomic neuropathy on abnormal gastrointestinal transit was assessed by univariate analysis and Bayesian multiple regression analysis. Accelerated gastrointestinal transit was found in 11 patients who showed abnormally rapid arrival of the meal marker to the cecum. Univariate and Bayesian analysis showed that diabetes mellitus and autonomic neuropathy had significant influences on rapid transit, which was not associated with either malabsorption or malnutrition. In conclusion, rapid gastrointestinal transit in patients with alcohol-related chronic pancreatitis is related to diabetes mellitus and autonomic neuropathy.

W2077 Rapid Gastrointestinal Transit in Patients with Alcohol-Related Chronic Pancreatitis Is Related to Impaired Distal Small Bowel Meal Accumulation and Autonomic Neuropathy

Background: Patients with alcohol-related chronic pancreatitis (ARCP) may have accelerated mouth-to-cecum transit, particularly in the presence of autonomic neuropathy. Nevertheless, the roles of gastric emptying (GE) and transit throughout proximal and distal small bowel in the origin of the abnormal gastrointestinal transit (GIT) in ARCP have not been much studied. Aim: To assess GIT and to determine the roles of GE and segmental transit throughout the proximal and the distal small bowel in ARCP patients. Method: Eighteen healthy controls and 40 male ARCP patients were studied, including 17 with diabetes mellitus and malabsorption, 10 with diabetes only, 3 with malabsorption only and 10 without diabetes or malabsorption. Autonomic neuropathy was detected in 20 patients by standardized cardiovascular tests. GIT was assessed by scintigraphy after ingestion of a liquid meal labeled with 99mTechnetium-phytate and defined as the time of meal arrival to the cecum. Abdominal scans were serially taken for 180 min with a gamma camera. Counts for regions of interest defined for the stomach, proximal and distal small bowel, and cecum yield data for calculation for GE half-time, and the times of meal arrival to the proximal and to the distal small bowel and the cecum. Accumulation of the meal in the distal small bowel was estimated as the proportion of ingested radioactivity found in this region by the time that cecum filling started. Results: GIT was significantly shorter (p 180min vs 102min; 50->180min) and 11 patients were considered as having definite abnormally accelerated GIT. There were no significant differences (p>0.20) between patients and controls concerning GE half-time (50min; 5-13min vs 55min; 16-83min). There were also no differences (p>0.50) between patients and controls regarding the times of meal arrival to the proximal (15min; 1-45min vs 13min; 3-70min) and distal small bowel (23min; 4-64min vs 30min; 12-83min). However, accumulation of the meal in the distal small bowel was lower (p 0.1). Univariate analysis showed that rapid GIT is associated with both impaired accumulation of the meal in the distal small bowel (7/11 vs 3/29; p=0.001) and autonomic neuropathy (10/11 vs 10/29; p= 0.003). Conclusion: Abnormally rapid GIT in ARCP patients does not seem to be due to accelerated GE but is related to impaired accumulation of the meal in the distal small bowel and to autonomic neuropathy.