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Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill.
Deane, AM, Chapman, MJ, Reintam Blaser, A, McClave, SA, Emmanuel, A
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2019;(1):23-36
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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2.
Novel transmitters in brain stem vagal neurocircuitry: new players on the pitch.
Bülbül, M, Travagli, RA
American journal of physiology. Gastrointestinal and liver physiology. 2018;(1):G20-G26
Abstract
The last few decades have seen a major increase in the number of neurotransmitters and neuropeptides recognized as playing a role in brain stem neurocircuits, including those involved in homeostatic functions such as stress responsiveness, gastrointestinal motility, feeding, and/or arousal/wakefulness. This minireview will focus on the known physiological role of three of these novel neuropeptides, i.e., apelin, nesfatin-1, and neuropeptide-S, with a special emphasis on their hypothetical roles in vagal signaling related to gastrointestinal motor functions.
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Postural Tachycardia Syndrome (POTS) and the GI Tract: A Primer for the Gastroenterologist.
DiBaise, JK, Harris, LA, Goodman, B
The American journal of gastroenterology. 2018;(10):1458-1467
Abstract
Postural tachycardia syndrome (POTS) is one of the most common causes of orthostatic intolerance and is being increasingly recognized in clinical practice. Gastrointestinal (GI) symptoms are reported commonly in patients with POTS and pose a considerable management challenge, making it imperative that gastroenterologists be aware of this condition and its GI comorbidities. Although the evidence presented herein does not prove causation, it does support an association between GI symptoms, GI dysmotility, and POTS. At present, the evaluation and treatment of GI symptoms in patients with POTS remains largely empirical. General measures to treat POTS may lead to improvement in both GI and non-GI symptoms. GI symptoms refractory to these measures should prompt further diagnostic evaluation of gastrointestinal dysmotility and appropriate dietary and pharmacologic management. This review focuses its attention on the involvement of the GI tract in POTS including a discussion of GI symptoms and conditions associated with POTS, followed by an analysis of abnormalities in gut physiology described in POTS, and concluding with an overview of management and suggestions for research directions.
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In Search of the Ideal Promotility Agent: Optimal Use of Currently Available Promotility Agents for Nutrition Therapy of the Critically Ill Patient.
Diamond, SJ, Omer, E, Kiraly, L
Current gastroenterology reports. 2017;(12):63
Abstract
PURPOSE OF REVIEW Enteral nutrition therapy is essential in the management of critically ill patients. Prokinetic agents have been used successfully to aid in the delivery of nutrition and improve feeding tolerance in patients in the intensive care unit (ICU). The aim of this report is to review the existing promotility agents available for use in the critically ill as well as outline the role of potential investigative drugs in order to provide a guide to the management of this difficult and important clinical dilemma. RECENT FINDINGS While no single currently available agent currently meets all of the desired goals in the critical care setting, there are an increasing number of available agents from which to choose including motilin receptor agonists, 5HT4 receptor agonists, D2 receptor antagonists, and Mu opioid receptor antagonists. We recommend a multifaceted approach to optimizing enteral nutrition in the critical care setting which should include the early, prophylactic use of promotility agents and should focus on the management of reversible causes of impaired gastrointestinal motility.
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5.
Chewing gum for intestinal function recovery after caesarean section: a systematic review and meta-analysis.
Wen, Z, Shen, M, Wu, C, Ding, J, Mei, B
BMC pregnancy and childbirth. 2017;(1):105
Abstract
BACKGROUND Gum chewing has been reported to enhance the intestinal function recovery after caesarean section, current perspectives and practice guidelines vary widely on the use of gum chewing, more studies on the role of gum chewing after caesarean section are needed. METHODS We performed a comprehensive, systematic meta-analysis of randomized controlled trials (RCTs) on the efficacy of gum chewing after caesarean section. Studies were identified by searching EMBASE et al database (until June 30, 2016). Summary odd ratios or weighted mean differences with 95% confidence intervals were calculated for each outcome with fixed- or random-effects model. RESULTS Ten RCTs with a total of 1659 women were included in our meta-analysis. Gum chewing provided significant benefits in reducing the time to first passage of flatus, first defecation, first bowel sound, first bowel movement and the length of hospital stay, but not in the time to first feeling of hunger. CONCLUSIONS Gun chewing hastens the intestinal function recovery after caesarean section and offers a safe and inexpensive option. High-quality and larger-scale RCTs are still warranted to clarify the role of gum chewing in intestinal function recovery after caesarean section.
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Modulation of gastrointestinal motility beyond metoclopramide and domperidone : Pharmacological and clinical evidence for phytotherapy in functional gastrointestinal disorders.
Madisch, A, Vinson, BR, Abdel-Aziz, H, Kelber, O, Nieber, K, Kraft, K, Storr, M
Wiener medizinische Wochenschrift (1946). 2017;(7-8):160-168
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Abstract
The prokinetic cisapride, an important therapeutic option in functional gastrointestinal (GI) disorders, was withdrawn from the market 15 years ago due to rare severe side effects. Likewise in 2014, the use of metoclopramide (MCP) and domperidone in functional GI disorders (FGID) was restricted, consequently leaving a therapeutic gap in clinical practice. A systematic review revealed that the herbal medicinal product (HMP) STW 5 presents a therapeutic option equivalent to MCP and cisapride. STW 5 is the only HMP for which efficacy has been shown in randomized controlled clinical trials (RCTs) in functional dyspepsia and irritable bowel syndrome, based on its multitarget effect on numerous etiological factors. Due to an outstanding favorable safety profile, STW 5 allows an effective and safe use in FGID without a limitation of the duration of the treatment.
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[The use of chewing gum stimulates bowel motility after gynaecological surgery].
Amirian, I, Gögenur, I
Ugeskrift for laeger. 2016;(14):V02160093
Abstract
Post-operative ileus is a condition which occurs after abdominal surgery. The incidence of post-operative ileus after gynaecological surgery is estimated to be 10-15% (range: 5-25%). The highest rates occur after laparotomy. Chewing gum stimulates bowel motility after gynaecological surgery and reduces time to first flatulence and faeces. Data on reduction in ileus symptoms and reduced hospital stay are not sufficient. Chewing gum is well tolerated and this article recommends it for post-operative optimization.
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Modern Management of Irritable Bowel Syndrome: More Than Motility.
Tack, J, Vanuytsel, T, Corsetti, M
Digestive diseases (Basel, Switzerland). 2016;(5):566-73
Abstract
In the treatment of irritable bowel syndrome (IBS), loperamide seems efficacious for diarrhea and ispaghula for constipation, while musculotropic spasmolytics may relieve abdominal pain. Antidepressants were found to be efficacious for abdominal pain, but their tolerance may be problematic and the therapeutic effect varied largely between trials. While meta-analyses suggest efficacy of probiotics as a group, the quality of the trials is often suboptimal and there is large variability. Lubiprostone, a chloride channel activator, and linaclotide, a guanylyl cyclase-C agonist, showed favorable effects on multiple symptoms in IBS with constipation. For IBS with diarrhea (IBS-D), the 5-HT3 receptor antagonist ramosetron showed efficacy in men and women, but is currently only approved in Japan. A multicenter study with the anti-emetic 5-HT3 receptor antagonist ondansetron showed efficacy on stool pattern in IBS-D. The poorly absorbable antibiotic rifaximin and eluxadoline, a mu opioid receptor agonist and delta antagonist, both showed efficacy in phase III trials in IBS-D and were approved by the FDA. Eluxadoline was associated with increased occurrence of sphincter of Oddi spasm and biliary pancreatitis. The non-pharmacological treatment of IBS, with dietary interventions (mainly gluten elimination and low FODMAP (fructose, oligo-, di-, monosaccharides and polyols)) has received a lot of attention lately. While responder rates vary across studies, perhaps based on regional variations in dietary intake of FODMAPs, the dietary approach seems to have acquired recognition as a valid therapeutic alternative. Long-term studies and comparative studies with pharmacotherapy, as well as elucidation of the underlying mechanisms of action, are needed.
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Combination could be another tool for bowel preparation?
Soh, JS, Kim, KJ
World journal of gastroenterology. 2016;(10):2915-21
Abstract
Optimal bowel preparation increases the cecal intubation rate and detection of neoplastic lesions while decreasing the procedural time and procedural-related complications. Although high-volume polyethylene glycol (PEG) solution is the most frequently used preparation for bowel cleansing, patients are often unwilling to take PEG solution due to its large volume, poor palatability, and high incidence of adverse events, such as abdominal bloating and nausea. Other purgatives include osmotic agents (e.g., sodium phosphate, magnesium citrate, and sodium sulfate), stimulant agents (e.g., senna, bisacodyl, and sodium picosulfate), and prokinetic agents (e.g., cisapride, mosapride, and itopride). A combination of PEG with an osmotic, stimulant, or prokinetic agent could effectively reduce the PEG solution volume and increase patients' adherence. Some such solutions have been found in several published studies to not be inferior to PEG alone in terms of bowel cleansing quality. Although combination methods showed similar efficacy and safety, the value of these studies is limited by shortcomings in study design. New effective and well-tolerated combination preparations are required, in addition to rigorous new validated studies.
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10.
The Effect of Alcohol on Gastrointestinal Motility.
Grad, S, Abenavoli, L, Dumitrascu, DL
Reviews on recent clinical trials. 2016;(3):191-5
Abstract
The Gastrointestinal (GI) tract is one of the most affected systems by alcohol consumption. Alcohol can affect the esophagus in several ways: induces mucosal inflammation, increases the risk for Barrett esophagus and esophageal cancer, and also impairs the esophageal motility. Numerous studies have reported an increased prevalence of Gastroesophageal Reflux Disease (GERD) or erosive esophagitis in alcoholics. Some alcoholics exhibit an abnormality of esophageal motility known as a "nutcracker esophagus". Alcohol effect on gastric motility depends on the alcohol concentration. In general, beverages with high alcohol concentrations (i.e., above 15 percent) appear to inhibit gastric motility and low alcohol doses (wine and beer) accelerate gastric emptying. Also, acute administration of ethanol inhibits the gastric emptying, while chronic administration of a large dose of alcohol accelerates gastric motility. The effect of alcohol on small bowel motility differs according to the type of consumption (acute or chronic). Acute administration of alcohol has been found to inhibit small bowel transit and chronic administration of a large dose of alcohol accelerates small bowel transit. This article reviews some of the below findings.