Stamatiki Kritas

Small bowel bacterial overgrowth is a common cause of chronic diarrhea

Background and Aims:  Often a cause for chronic non‐specific diarrhea (≥3 stools per day for more than 4 weeks) is not identified. Small bowel bacterial overgrowth (SBO) can occur without morphological damage and remains difficult to diagnose. Often diarrhea is treated empirically with antibiotics with a good response. The aims of the present study were first to investigate the prevalence of SBO in a consecutive series of patients with chronic diarrhea and second to compare the utility of duodenal fluid culture and 14C‐d‐xylose breath/lactulose test in diagnosing SBO.

Optimisation of the Reflux-symptom Association Statistics for Use in Infants Being Investigated by 24-hour pH impedance

Background and Aim: pH-impedance monitoring is used to diagnose symptomatic gastroesophageal reflux (GER) based on symptom association probability (SAP). Current criteria for calculation of SAP are optimised for heartburn in adults. Infants, however, demonstrate a different symptom profile. The aim of the present study was to optimise criteria for calculation of SAP in infants with GER disease. Patients and Methods: Ten infants referred for investigation of symptomatic reflux were enrolled. GER episodes were recorded using a pH-impedance probe, which remained in place for 48 hours. During the test, cough, crying, and regurgitation were marked. Impedance recordings were analysed for the occurrence of bolus reflux episodes. SAP for behaviors following reflux episodes was separately calculated for day 1 and day 2 using automated reporting software, which enabled the time window used for SAP calculations to be modified from 15 to 600 seconds. Day-to-day agreement of SAP was assessed by calculating the 95% limits of agreement (mean difference ± 1.96 standard deviations of differences) and their confidence intervals. Results: The number of bolus GER episodes and symptom episodes reported did not differ from day to day. The best agreement in SAP between the 2 days was found using time intervals of 2 minutes for cough, 5 minutes for crying, and 15 seconds and/or 2 to 5 minutes for regurgitation. Conclusions: We conclude that the standard 2-minute time interval is appropriate for the investigation of cough and regurgitation symptoms. The day-to-day agreement of SAP for crying was poor using standard criteria, and our results suggest increasing the reflux-symptom association time interval to 5 minutes.

Pancreatic Enzyme Supplementation Improves the Incretin Hormone Response and Attenuates Postprandial Glycemia in Adolescents With Cystic Fibrosis: A Randomized Crossover Trial

CONTEXT Cystic fibrosis-related diabetes is characterized by postprandial, rather than fasting, hyperglycemia. Gastric emptying and the release of the incretin hormones [glucagon-like peptide-1 (GLP-1) and glucose dependent insulinotropic polypeptide (GIP)] are central to postprandial glycemic control. Lipolysis is required for fat to slow gastric emptying and stimulate incretin release. OBJECTIVE We aimed to determine the effect of pancreatic enzyme replacement therapy (PERT) on postprandial glycemia in adolescents with cystic fibrosis (CF). DESIGN This was a double-blinded randomized crossover trial. Subjects consumed a high-fat pancake, with either PERT (50 000 IU lipase) or placebo. Gastric emptying was measured by a breath test and blood sampled frequently for plasma blood glucose, insulin, glucagon, GLP-1, and GIP. Data were also compared with seven healthy subjects. PARTICIPANTS Fourteen adolescents (13.1 ± 2.7 y) with pancreatic-insufficient CF and seven healthy age-matched controls participated in the study. MAIN OUTCOME MEASURE Postprandial hyperglycemia was measured as peak glucose and area under the curve for blood glucose at 240 minutes. RESULTS CF subjects had postprandial hyperglycemia compared with controls (area under the curve, P < .0001). PERT reduced postprandial hyperglycemia (P = .0002), slowed gastric emptying (P = .003), and normalized GLP-1 and GIP secretion (P < .001 for each) when compared with placebo, without affecting insulin. CONCLUSION In young people with pancreatic insufficient CF, PERT markedly attenuates postprandial hyperglycemia by slowing gastric emptying and augmenting incretin hormone secretion.

Swallowing dysfunction in healthy older people using pharyngeal pressure-flow analysis

Age‐related loss of swallowing efficiency may occur for multiple reasons. Objective assessment of individual dysfunctions is difficult and may not clearly differentiate these from normal. Pharyngeal pressure‐flow analysis is a novel technique that allows quantification of swallow dysfunction predisposing to aspiration risk based on a swallow risk index (SRI). In this study, we examined the effect of ageing on swallow function.

Oesophageal pressure-flow metrics in relation to bolus volume, bolus consistency, and bolus perception

Background The utility of combined oesophageal pressure–impedance recording has been enhanced by automation of data analysis. Objective To understand how oesophageal function as measured by automated impedance manometry (AIM) pressure-flow analysis varies with bolus characteristics and subjective perception of bolus passage. Methods Oesophageal pressure–impedance recordings of 5 and 10 ml liquid or viscous swallows and 2 and 4 cm solid swallows from 20 healthy control subjects (five male; 25–73 years) were analysed. Metrics indicative of bolus pressurization (intrabolus pressure and intrabolus pressure slope) were derived. Bolus flow resistance, the relationship between bolus pressurization and flow timing, was assessed using a pressure-flow index. Bolus retention was assessed using the ratio of nadir impedance to peak pressure impedance (impedance ratio). Subjective perception of bolus passage was assessed swallow by swallow. Results Viscosity increased the bolus flow resistance and reduced bolus clearance. Responses to boluses of larger volume and more viscous consistency revealed a positive correlation between bolus pressurization and oesophageal peak pressure. Flow resistance was higher in subjects who perceived bolus hold up of solids. Conclusions Bolus volume and bolus type alter oesophageal function and impact AIM analysis metrics descriptive of oesophageal function. Perception of bolus transit was associated with heightened bolus pressurization relative to bolus flow.

Whey- vs Casein-Based Enteral Formula and Gastrointestinal Function in Children With Cerebral Palsy

OBJECTIVES Children with severe cerebral palsy (CP) commonly have gastrointestinal (GI) dysfunction. Whey-based enteral formulas have been postulated to reduce gastroesophageal reflux (GOR) and accelerate gastric emptying (GE). The authors investigated whether whey-based (vs casein-based) enteral formulas reduce GOR and accelerate GE in children who have severe CP with a gastrostomy and fundoplication. METHODS Thirteen children received a casein-based formula for 1 week and either a 50% whey whole protein (50% WWP) or a 100% whey partially hydrolyzed protein (100% WPHP) formula for 1 week. Reflux episodes, gastric half-emptying time (GE t(1/2)), and reported pain and GI symptoms were measured. RESULTS Whey formulas emptied significantly faster than casein (median [interquartile range (IQR)] GE t(1/2), 33.9 [25.3-166.2] min vs 56.6 [46-191] min; P = .033). Reflux parameters were unchanged. GI symptoms were lower in children who received 50% WWP (visual analog symptom score, median [IQR], 0 [0-11.8]) vs 100% WPHP (13.0 [2.5-24.8]) (P = .035). CONCLUSION This pilot study shows that in children who have severe CP with a gastrostomy and fundoplication, GE of the whey-based enteral formula is significantly faster than casein. The acceleration in GE does not alter GOR frequency, and there appears to be no effect of whey vs casein in reducing acid, nonacid, and total reflux episodes. The results indicate that enteral formula selection may be particularly important for children with severe CP and delayed GE.

Applying the Chicago Classification criteria of esophageal motility to a pediatric cohort: effects of patient age and size

Applying the 2012 Chicago Classification (CC) of esophageal motility disorders to pediatric patients is problematic as it relies upon adult‐derived criteria. As shorter esophageal length and smaller esophago‐gastric junction (EGJ) diameter may influence CC metrics, we explored the potential for age‐ and size‐adjustment of diagnostic criteria.

Body positioning and medical therapy for infantile gastroesophageal reflux symptoms.

Objective:Proton-pump inhibitors (PPIs) reduce acid gastroesophageal reflux (GER) and esophageal acid exposure in infants; however, they do not reduce total GER or symptoms attributed to GER. Reflux is reduced in the left lateral position (LLP). We hypothesize that the effect of LLP in combination with acid suppression is most effective in reducing GER symptoms in infants. Methods:In this prospective sham-controlled trial, infants (0–6 months) with symptoms suggestive of gastroesophageal reflux disease were studied using 8-hour pH-impedance, cardiorespiratory and video monitoring, direct nurse observation, and a validated questionnaire. Infants demonstrating a positive GER symptom association were randomized to 1 of 4 groups; PPI + LLP, PPI + head of cot elevation (HE), antacid (AA) + LLP, or AA + HE. HE and AA were considered “sham” therapies. After 2 weeks the 8-hour studies were repeated on-therapy. Results:Fifty-one patients were included (aged 13.6 [2–26] weeks). PPI + LLP was most effective in reducing GER episodes (69 [13] to 46 [10], P < 0.001) and esophageal acid exposure (median [interquartile range] 8.9% [3.1%–18.1%] to 1.1% [0%–4.4%], P = 0.02). No treatment group showed improvement in crying/irritability, although vomiting was reduced in AA + LLP (from 7 [2] to 2 [0] episodes P = 0.042). LLP compared with HE produced greater reduction in total GER (−21 [4] vs −10 [4], P = 0.056), regardless of acid-suppressive therapy. Acid exposure was reduced on PPI compared with AA (−6.8 [2.1] vs −0.9 [1.4]%, pH < 4, P = 0.043) regardless of positional intervention. A post-hoc analysis using automated analysis software revealed a significant reduction in crying symptoms in the PPI + LLP group (99 [65–103] to 62 [32–96] episodes, P = 0.018). Conclusions:“Symptomatic gastroesophageal reflux disease” implies disease causation for distressing infant symptoms. In infants with symptoms attributed to GER, LLP produced a significant reduction in total GER, but did not result in a significant improvement in symptoms other than vomiting; however, automated analysis appeared to identify infants with GER-associated crying symptoms who responded to positioning therapy. This is an important new insight for future research.

Modulation of murine gastric vagal afferent mechanosensitivity by neuropeptide W.

Neuropeptide W (NPW) is an endogenous ligand for the receptors GPR7 and GPR8 and is involved in central regulation of energy homeostasis. NPW in the periphery is found in gastric gastrin (G) cells. In the stomach, energy intake is influenced by vagal afferent signals, so we aimed to determine the effect of NPW on mechanosensitive gastric vagal afferents under different feeding conditions.

New insights into pharyngo-esophageal bolus transport revealed by pressure-impedance measurement

Background  Pharyngeal propulsion, strength of peristalsis and esophago–gastric junction (EJG) resistance are determinants of esophageal bolus transport. This study used pressure‐impedance methods to correlate pharyngo‐esophageal function with the esophageal bolus trajectory pathway and pressures generated during bolus transport.