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      Measures of Autonomic Dysfunction in Diabetic and Idiopathic Gastroparesis

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          Abstract

          Background

          Gastroparesis is a condition classically characterized by delayed gastric emptying and is associated with considerable morbidity. While the etiology of gastroparesis remains elusive, autonomic dysfunction may play an important role, especially as many patients with gastroparesis also have diabetes. The aim of this study was to determine whether measures of autonomic function differ between adults with diabetic gastroparesis (DG) and adults with idiopathic gastroparesis (IG).

          Methods

          Tests of systemic autonomic function were performed among 20 adults with GD (six men and 14 women, mean age: 42 years) and 21 adults with IG (seven men and 14 women, mean age: 37 years). Measures included vagal cholinergics by R-R interval percentage variation (RRI-PV) and sympathetic adrenergics by vasoconstriction to cold (VC) and postural adjustment ratio (PAR). The two groups were compared using Wilcoxon rank sum tests and linear regression analysis (STATA 10.0).

          Results

          In univariate analysis, the following autonomic measures differed significantly between DG and IG: VC (P = 0.004), PAR (P = 0.045), VC + PAR (P = 0.002) and RRI-PV (P < 0.001). In multivariate analysis (P = 0.002, R 2 = 0.55), only RRI-PV (adjusted odds ratio (aOR): 1.02, 95% confidence interval (CI): 1.01 - 1.03) differed significantly between DG and IG patients.

          Conclusions

          Vagal cholinergics are affected to a greater degree in DG compared to IG, suggesting that impaired vagal tone is not a universal mechanism for gastroparesis.

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          Most cited references16

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          Clinical guideline: management of gastroparesis.

          Michael Camilleri, Henry Parkman, Mehnaz Shafi … (2013)
          This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.
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            Diabetic neuropathies: a statement by the American Diabetes Association.

            Adina L. Feldman, Jay Sosenko, Vera Bril … (2005)
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              Gastric electrical stimulation for medically refractory gastroparesis.

              Thomas Abell, Richard McCallum, Michael P. Hocking … (2003)
              This study investigated the efficacy of gastric electrical stimulation for the treatment of symptomatic gastroparesis unresponsive to standard medical therapy. Thirty-three patients with chronic gastroparesis (17 diabetic and 16 idiopathic) received continuous high-frequency/low-energy gastric electrical stimulation via electrodes in the muscle wall of the antrum connected to a neurostimulator in an abdominal wall pocket. After implantation, patients were randomized in a double-blind crossover design to stimulation ON or OFF for 1-month periods. The blind was then broken, and all patients were programmed to stimulation ON and evaluated at 6 and 12 months. Outcome measures were vomiting frequency, preference for ON or OFF, upper gastrointestinal tract symptoms, quality of life, gastric emptying, and adverse events. In the double-blind portion of the study, self-reported vomiting frequency was significantly reduced in the ON vs. OFF period (P < 0.05) and this symptomatic improvement was consistent with the significant patient preference (P < 0.05) for the ON vs. OFF period determined before breaking the blind. In the unblinded portion of the study, vomiting frequency decreased significantly (P < 0.05) at 6 and 12 months. Scores for symptom severity and quality of life significantly improved (P < 0.05) at 6 and 12 months, whereas gastric emptying was only modestly accelerated. Five patients had their gastric electrical stimulation system explanted or revised because of infection or other complications. High-frequency/low-energy gastric electrical stimulation significantly decreased vomiting frequency and gastrointestinal symptoms and improved quality of life in patients with severe gastroparesis.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Gastroenterology Res
                Journal ID (iso-abbrev): Gastroenterology Res
                Journal ID (publisher-id): Elmer Press
                Title: Gastroenterology Research
                Publisher: Elmer Press
                ISSN (Print): 1918-2805
                ISSN (Electronic): 1918-2813
                Publication date (Print): October 2016
                Publication date (Electronic): 20 September 2016
                Volume: 9
                Issue: 4-5
                Pages: 65-69
                Affiliations
                [a ]Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
                [b ]Department of Medicine, University of Mississippi Medical Center, Jackson, MS; Critical Care Medicine Department, National Institutes of Health, Bethesda, MD, USA
                [c ]AmeriPath Indiana, Indianapolis, IN, USA
                [d ]US Army Research, Development and Engineering Command, NVESD, Ft. Belvoir, VA, USA
                [e ]Neuroscience Institute and Cancer Center, Methodist University Hospital, Memphis, TN, USA
                [f ]Division of Public Health, Wake Forest School of Medicine, Winston Salem, NC, USA
                Author notes
                [g ]Corresponding Author: Thomas L. Abell, Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, 550 S. Jackson Street, ACB3 A3L15, Louisville, KY 40202, USA. Email: thomas.abell@ 123456louisville.edu
                Article
                DOI: 10.14740/gr713w
                PMC ID: 5040547
                SO-VID: 69d11615-c1bc-4154-8830-a34ea7447efa
                Copyright © Copyright 2016, Mohammad et al.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date accepted : 15 August 2016
                Categories
                Subject: Original Article

                Keywords: gastroparesis,diabetes,autonomic nervous system,sympathetic function,vagal dysfunction
                Data availability:
                Keywords: gastroparesis, diabetes, autonomic nervous system, sympathetic function, vagal dysfunction

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