Zubair A. Malik

Assessing pyloric sphincter pathophysiology using EndoFLIP in patients with gastroparesis

Pyloric dysfunction has been associated with gastroparesis, particularly diabetic gastroparesis. Endoscopic functional luminal imaging probe (EndoFLIP) uses 16 sensors inside a balloon that is inflated inside a sphincter to assess physiologic characteristics. The aim of this study was to measure the pressure, diameter, cross‐sectional area (CSA), and distensibility of the pylorus using EndoFLIP in patients with gastroparesis. In addition, the relationship between pyloric pathophysiology with gastroparesis etiology, symptoms, and gastric emptying was assessed.

The Role of Cannabinoids in Regulation of Nausea and Vomiting, and Visceral Pain

Marijuana derived from the plant Cannabis sativa has been used for the treatment of many gastrointestinal (GI) disorders, including anorexia, emesis, abdominal pain, diarrhea, and others. However, its psychotropic side effects have often limited its use. Several cannabinoid receptors, which include the cannabinoid receptor 1 (CB1), CB2, and possibly GPR55, have been identified throughout the GI tract. These receptors may play a role in the regulation of food intake, nausea and emesis, gastric secretion and gastroprotection, GI motility, ion transport, visceral sensation, intestinal inflammation, and cell proliferation in the gut. However, the regulation of nausea and vomiting by cannabinoids and the endocannabinoid system has shed new knowledge in this field. Thus far, despite evidence of visceral sensitivity inhibition in animal models, data in irritable bowel syndrome (IBS) patients is scarce and not supportive. Furthermore, many compounds that either act directly at the receptor or increase (or reduce) ligand availability have the potential to affect other brain functions and cause side effects. Novel drug targets such as FAAH and monoacylglycerol lipase (MAGL) inhibitors appear to be promising in animal models, but more studies are necessary to prove their efficiency. The promise of emerging drugs that are more selective and peripherally acting suggest that, in the near future, cannabinoids will play a major role in managing an array of GI diseases.

Profile of rifaximin and its potential in the treatment of irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by recurrent abdominal pain and abnormal bowel patterns. Alteration in gut flora, visceral hypersensitivity, and abnormal bowel motility are among numerous factors in the complex pathophysiology of IBS. Antibiotics have been used adjunctively to treat IBS for many years but are associated with various systemic side effects. Rifaximin is a nonabsorbable, broad-spectrum antimicrobial that inhibits bacterial RNA synthesis by binding the β-subunit of microbial RNA polymerase. It targets the gastrointestinal tract and works by reducing the quantity of gas-producing bacteria and altering the predominant species of bacteria present. In vivo animal studies suggest additional beneficial mechanisms of rifaximin, including reducing mucosal inflammation and visceral hypersensitivity. Clinical studies have demonstrated that rifaximin improves symptoms associated with IBS, such as bloating, flatulence, stool consistency, and abdominal pain, and has a side-effect profile similar to placebo. Although additional investigation into optimal dosing, treatment duration, and potential resistance is required, rifaximin presents as a safe and beneficial addition to the current management options for IBS.

Acute Esophageal Necrosis Presenting With Henoch-Schönlein Purpura.

A 63-year-old woman with abdominal pain and melena developed a palpable, purpuric rash and acute kidney injury. Skin and kidney biopsy confirmed Henoch-Schönlein purpura. Upper endoscopy revealed diffuse, circumferential, black-appearing mucosa of the esophagus consistent with acute esophageal necrosis (AEN), also known as black esophagus. AEN is a very rare cause of gastrointestinal hemorrhage with a high mortality risk. To our knowledge, there have been no prior reports of AEN associated with Henoch-Schonlein purpura or other vasculitis.

Post-Fundoplication Dumping Syndrome: A Frequent “Rare” Complication

Gastroparesis, caused by delayed emptying of the stomach, has been shown to be associated with Nissen fundoplication. However, symptomatic rapid emptying of the stomach is rare after Nissen fundoplication, and its treatment is often challenging. We report 2 patients with dumping-like syndrome post-fundoplication with marked improvement of symptoms after dietary management and medical treatment.

Características del esfínter pilórico utilizando EndoFLIP® en gastroparesia

INTRODUCTION AND AIMS Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP®) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection. METHODS EndoFLIP® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12. RESULTS Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain. CONCLUSIONS EndoFLIP® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus.

Massive Esophageal Variceal Bleeding as a Rare Complication of Sickle Cell Anemia

A 24-year-old man with sickle cell anemia presented with fatigue, dark stool, and coffee ground emesis. He was found to have large esophageal varices and experienced massive variceal hemorrhage in the hospital. The varices were caused by diffuse splanchnic venous thrombosis, and his only risk factor for hypercoagulability was sickle cell anemia. Splanchnic venous thrombosis due to sickle cell anemia is exceedingly rare.

Sa2040 Role of Ethnicity in the Presentation, Evaluation, and Etiology of Severe Constipation

INTRODUCTION: Hospitalized patients suffer disproportionately from constipation during their stays, however little data exists to guide clinicians in prophylaxis against in-hospital constipation. We performed a retrospective, cohort analysis of patients admitted to a quaternary care center with congestive heart failure (CHF) to determine the effects of inpatient bowel prophylaxis on inpatient constipation. METHODS: All patients admitted to a quaternary care center with the primary diagnosis of CHF or its equivalent in 2012 (n=802) were evaluated for use of a standing bowel regimen on admission. Constipation was defined as new laxative use after 24 hours of admission, which reflected patient/nursing request or provider judgment that laxation was needed. We chose to examine CHF hospitalizations because predictors of length of stay in this population have been well established in previous studies and constipation tracks with longer stays. We incorporated these previously-validated predictors of length of stay in combination with known and proposed predictors of constipation to create a model for inpatient incidence of constipation. We used this model to examine the effects of in-house constipation prophylaxis on new constipation during admission via logistic regression with estimation of odds ratios and 95% confidence intervals. RESULTS: 802 admissions were examined with 10 admissions excluded because the patients underwent colonoscopy with bowel preparation during their hospitalization. The remaining 792 patients were included to form the final regression model which included demographics (56% male, 85% white, mean age of 75), in-hospital mortality (1%), comorbidities, home medications, admission lab values, bowel prophylaxis on admission, and inpatient medications with the potential to cause constipation. In-hospital constipation occurred in 28.8% of admissions, including 19.0% of patients receiving no bowel prophylaxis and 9.7% of patients receiving prophylaxis. Home laxative use conferred a significantly-increased risk of constipation compared to patients not using laxatives at home (OR 3.6, 95% CI 2.1-6.3) and patients with home laxative use who were placed on inpatient bowel prophylaxis had a significantlydecreased risk of constipation compared to those who were not given prophylaxis on admission (OR 0.24, 95% CI 0.12-0.47). The use of sennosides/docusate combination prophylaxis significantly decreased the risk of constipation (OR 0.32, 95% CI 0.10-0.99) while sennosides and docusate monotherapy had no effect. CONCLUSIONS: Constipation is a common complication of inpatient stays for CHF, but our data suggests the risk is highest for patients taking laxatives at home. The risk of in-hospital constipation could be mitigated by giving sennosides/docusate prophylactic therapy on admission—especially to patients with preexisting constipation.