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1.
Gastric content and perioperative pulmonary aspiration in patients with diabetes mellitus: a scoping review.
Xiao, MZX, Englesakis, M, Perlas, A
British journal of anaesthesia. 2021;(2):224-235
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Abstract
BACKGROUND Gastric emptying may be delayed in patients with diabetes mellitus (DM). However, the incidence of full stomach in fasting patients with DM and their risk of pulmonary aspiration under anaesthesia is not well understood. METHODS A scoping review was undertaken to map the literature on aspiration risk in DM. A search was conducted in seven bibliographic databases, including MEDLINE and Embase, for original articles that studied aspiration risk, gastric emptying, or gastric content and volume. Selection and characterisation were performed by two independent reviewers using a predefined protocol registered externally. RESULTS The search identified 5063 unique records, and 16 studies (totalling 775 patients with DM) were selected: nine studied gastric emptying and seven studied gastric content or volume. There were no studies reporting the incidence of aspiration in subjects with DM. All nine studies reported delayed emptying in patients with DM compared with healthy controls. Amongst the seven studies that compared gastric residual content/volume (GRV) in the perioperative period, five reported clinically negligible GRV in both patients with DM and controls, whereas two observed a higher incidence of 'full' stomach in patients with DM. CONCLUSIONS The evidence concerning the aspiration risk for surgical patients with DM is based on a limited number of studies, mostly unblinded, reporting physiological data on gastric emptying and gastric volume as surrogate markers of aspiration risk. Data on fasting gastric content and volume in patients with DM are limited and contradictory; hence, the true risk of aspiration in fasting patients with DM is unknown.
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Gastrointestinal hormones and regulation of gastric emptying.
Camilleri, M
Current opinion in endocrinology, diabetes, and obesity. 2019;(1):3-10
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Abstract
PURPOSE OF REVIEW This review examines the hormonal regulation of gastric emptying, a topic of increasing relevance, given the fact that medications that are analogs of some of these hormones or act as agonists at the hormonal receptors, are used in clinical practice for optimizing metabolic control in the treatment of type 2 diabetes and in obesity. RECENT FINDINGS The major effects on gastric emptying result from actions of incretins, particularly gastric inhibitory polypeptide, glucagon-like peptide-1, and peptide tyrosine-tyrosine, the duodenal and pancreatic hormones, motilin, glucagon, and amylin, and the gastric orexigenic hormones, ghrelin and motilin. All of these hormones delay gastric emptying, except for ghrelin and motilin which accelerate gastric emptying. These effects on gastric emptying parallel the effects of the hormones on satiation (by those retarding emptying) and increase appetite by those that accelerate emptying. Indeed, in addition to the effects of these hormones on hypothalamic appetite centers and glycemic control, there is evidence that some of their biological effects are mediated through actions on the stomach, particularly with the glucagon-like peptide-1 analogs or agonists used in treating obesity. SUMMARY Effects of gastrointestinal hormones on gastric emptying are increasingly recognized as important mediators of satiation and postprandial glycemic control.
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Rapid gastric emptying in diabetes mellitus: Pathophysiology and clinical importance.
Goyal, RK, Cristofaro, V, Sullivan, MP
Journal of diabetes and its complications. 2019;(11):107414
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Although slow gastric emptying (gastroparesis) is a well-known complication of chronic hyperglycemia in diabetes mellitus (DM), it recently has become clear that rapid gastric emptying also is a frequent and important diabetic complication. In contrast, acute hyperglycemia causes slow gastric emptying, and acute hypoglycemia causes rapid gastric emptying. Rapid gastric emptying is frequent in T2DM; however, it may also occur in T1DM, particularly in the early stages of the disease, but may persist even into late stages. Recent studies suggest that usually, the stomach restricts the emptying of nutrients to 1-4 kcals/min. This restriction is due to the action of the gastric 'braking' hormones such as GLP-1, leptin, and amylin acting via the gastric inhibitory vagal motor circuit (GIVMC). Disruption of this braking system leads to rapid gastric emptying. Acute hyperglycemia also slows gastric emptying by stimulating the GIVMC, while acute hypoglycemia causes rapid gastric emptying by stimulating the gastric excitatory vagal motor circuit (GEVMC). In contrast, chronic hyperglycemia causes rapid gastric emptying by inducing oxidative stress in the stomach wall that disrupts inhibitory neuromuscular transmission and increases the contractility of the smooth muscle, while chronic hyperglycemia may also cause slow gastric emptying via severe inflammatory stress caused by proinflammatory macrophages and reduce contractility of the smooth muscle. There is a bidirectional relationship between blood glucose and gastric emptying. Thus, rapid gastric emptying may lead to a sizeable postprandial spike, and slow gastric emptying may blunt it. Postprandial hyperglycemia is involved in the development, progression, and complications of DM. Correction of fast gastric emptying involves agents that activate GIVMC and the use of gastric 'braking' hormones or their analogs. Recognition and treatment of rapid gastric emptying may contribute to better management of postprandial hyperglycemia and prevention of some diabetic complications.
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Postprandial Glucose Control in Type 1 Diabetes: Importance of the Gastric Emptying Rate.
Lupoli, R, Pisano, F, Capaldo, B
Nutrients. 2019;(7)
Abstract
The achievement of optimal post-prandial (PP) glucose control in patients with type 1 diabetes (T1DM) remains a great challenge. This review summarizes the main factors contributing to PP glucose response and discusses the likely reasons why PP glucose control is rarely achieved in T1DM patients. The macronutrient composition of the meal, the rate of gastric emptying and premeal insulin administration are key factors affecting the PP glucose response in T1DM. Although the use of continuous insulin infusion systems has improved PP glucose control compared to conventional insulin therapy, there is still need for further ameliorations. T1DM patients frequently present a delayed gastric emptying (GE) that produces a lower but more prolonged PP hyperglycemia. In addition, delayed GE is associated with a longer time to reach the glycemic peak, with a consequent mismatch between PP glucose elevation and the timing of premeal insulin action. On this basis, including GE time and meal composition in the algorithms for insulin bolus calculation of the insulin delivery systems could be an important step forward for optimization of PP glucose control in T1DM.
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Bidirectional Relationship between Gastric Emptying and Plasma Glucose Control in Normoglycemic Individuals and Diabetic Patients.
Mihai, BM, Mihai, C, Cijevschi-Prelipcean, C, Grigorescu, ED, Dranga, M, Drug, V, Sporea, I, Lăcătușu, CM
Journal of diabetes research. 2018;:1736959
Abstract
Gastric emptying and glycemic control pathways are closely interrelated processes. Gastric chyme is transferred into the duodenum with velocities depending on its solid or liquid state, as well as on its caloric and nutritional composition. Once nutrients enter the intestine, the secretion of incretins (hormonal products of intestinal cells) is stimulated. Among incretins, glucagon-like peptide-1 (GLP-1) has multiple glycemic-regulatory effects that include delayed gastric emptying, thus triggering a feedback loop lowering postprandial serum glucose levels. Glycemic values also influence gastric emptying; hyperglycemia slows it down, and hypoglycemia accelerates it, both limiting glycemic fluctuations. Disordered gastric emptying in diabetes mellitus is understood today as a complex pathophysiological condition, with both irreversible and reversible components and high intra- and interindividual variability of time span and clinical features. While limited delays may be useful for reducing postprandial hyperglycemias, severely hindered gastric emptying may be associated with higher glycemic variability and worsened long-term glycemic control. Therapeutic approaches for both gastric emptying and glycemic control include dietary modifications of meal structure or content and drugs acting as GLP-1 receptor agonists. In the foreseeable future, we will probably witness a wider range of dietary interventions and more incretin-based medications used for restoring both gastric emptying and glycemic levels to nearly physiological levels.
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Drug-resin drug interactions in patients with delayed gastric emptying: What is optimal time window for drug administration?
Camilleri, M
Neurogastroenterology and motility. 2016;(8):1268-71
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Most drug-drug interactions involve overlap or competition in drug metabolic pathways. However, there are medications, typically resins, whose function is to bind injurious substances such as bile acids or potassium within the digestive tract. The objective of this article is to review the functions of the stomach and the kinetics of emptying of different food forms or formulations to make recommendations on timing of medication administration in order to avoid intragastric drug interactions. Based on the profiles and kinetics of emptying of liquid nutrients and homogenized solids, a window of 3 h between administration of a resin drug and another 'target' medication would be expected to allow a median of 80% of medications with particle size <1 mm to empty from the stomach and, hence, avoid potential interaction such as binding of the 'target' medication within the stomach.
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Systematic review of the impact of feed protein type and degree of hydrolysis on gastric emptying in children.
Meyer, R, Foong, RX, Thapar, N, Kritas, S, Shah, N
BMC gastroenterology. 2015;:137
Abstract
BACKGROUND The choice of infant formula is thought to play an important role on gastric emptying (GE) in a variety of gastrointestinal disorders. It is known that many ingredients impact on GE, including the type of protein and level of hydrolysis. In clinical practice, feeds are often recommended due to putative improved GE related to the type of protein and level of hydrolysis, however whether this is scientifically justified still needs to be established. A systematic review comparing the impact of protein type and hydrolysis on GE in children was therefore performed. METHODS The Patient, Intervention, Comparison and Outcome system was used. A structured literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, searching PubMed, Cochrane databases and Google Scholar from 1990 to 2014. We only included articles published in full text English language using specific search terms, including both scintigraphy and C13-octanoic acid breath test. RESULTS We identified 126 publications of which 20 were eligible for inclusion but only 8 were included. Studies reviewed GE in both healthy children as well as those with neurodevelopmental delay and reflux. Two studies investigating GE of breast milk versus formula indicated a faster GE for breast milk. Four studies found that feeds containing whole whey in varying amounts emptied faster than predominant whole casein feeds and one study found no difference in GE. Five studies investigated a mix of whole versus hydrolysed protein and found conflicting results related to study population and hydrolysis. CONCLUSIONS Breast milk has a faster GE than formula milk. Although there seems to be a trend towards whey feeds emptying faster, different methodologies, feed compositions and patient groups makes it difficult to draw firm conclusions. Future studies should be performed with comparable feeds in populations where increased GE may be of clinical benefit.
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Xiangshaliujunzi Decoction for the treatment of diabetic gastroparesis: a systematic review.
Tian, JX, Li, M, Liao, JQ, Liu, WK, Tong, XL
World journal of gastroenterology. 2014;(2):561-8
Abstract
AIM: To assess the current clinical evidence of the effectiveness of Xiangshaliujunzi Decoction (XSLJZD) for the treatment of diabetic gastroparesis (DGP). METHODS Randomized controlled trials (RCTs) were retrieved from seven major electronic databases including Medline, the Cochrane Library, Embase, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database (VIP), and Wanfang Databases, using search dates from the beginning of the databases to May 2013. No language limitations were applied. We included RCTs that used XSLJZD or a modified XSLJZD compared with a control group for the treatment of DGP. The control groups included conventional treatment (Western medicinal treatment), placebo, and no treatment (blank), but not acupuncture. The main outcome index was clinical effectiveness, which was based on the gastric emptying test and variations in the gastrointestinal (GI) symptoms between the treatment and control groups after intervention. Data extraction, analysis, and quality assessment were conducted according to the Cochrane Handbook for Systematic Review of Interventions, Version 5.1.0. RESULTS Ten RCTs involving 867 patients (441 in the experimental groups, and 426 in the control groups) were identified, and the overall methodological quality was evaluated as generally low. In the treatment groups, all 10 trials used herbs alone as the treatment, whereas all control groups used prokinetic medicine. The period of intervention ranged from 2 to 8 wk. Three classes were used to evaluate treatment efficacy: significant effective, effective, and ineffective, and all trials used the clinical effective rate (based on the gastric emptying test and changes in GI symptoms) to evaluate efficacy. The data showed that the effects of XSLJZD for the treatment of DGP were superior to the control group (n = 867, RR =1.33, 95%CI: 1.24-1.42, Z = 8.11, P < 0.00001). Two trials recorded adverse events, and one trial reported follow-up. CONCLUSION XSLJZD could restore the gastric emptying rate and improve symptoms. However, the evidence remains weak due to the poor methodological quality of the included studies.
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Review article: the role of gastrointestinal hormones in the treatment of delayed gastric emptying in critically ill patients.
Luttikhold, J, de Ruijter, FM, van Norren, K, Diamant, M, Witkamp, RF, van Leeuwen, PA, Vermeulen, MA
Alimentary pharmacology & therapeutics. 2013;(6):573-83
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BACKGROUND Delayed gastric emptying limits the administration of enteral nutrition, leading to malnutrition, which is associated with higher mortality and morbidity. Currently available prokinetics have limitations in terms of sustained efficacy and side effects. AIM: To summarise the mechanisms of action and to discuss the possible utility of gastrointestinal hormones to prevent or treat delayed gastric emptying in critically ill patients. METHODS We searched PubMed for articles discussing 'delayed gastric emptying', 'enteral nutrition', 'treatment', 'gastrointestinal hormones', 'prokinetic', 'agonist', 'antagonist' and 'critically ill patients'. RESULTS Motilin and ghrelin receptor agonists initiate the migrating motor complex in the stomach, which accelerates gastric emptying. Cholecystokinin, glucagon-like peptide-1 and peptide YY have an inhibiting effect on gastric emptying; therefore, antagonising these gastrointestinal hormones may have therapeutic potential. Other gastrointestinal hormones appear less promising. CONCLUSIONS Manipulation of endogenous secretion, physiological replacement and administration of gastrointestinal hormones in pharmacological doses is likely to have therapeutic potential in the treatment of delayed gastric emptying. Future challenges in this field will include the search for candidates with improved selectivity and favourable kinetic properties.
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Review article: the role of gastric motility in the control of food intake.
Janssen, P, Vanden Berghe, P, Verschueren, S, Lehmann, A, Depoortere, I, Tack, J
Alimentary pharmacology & therapeutics. 2011;(8):880-94
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BACKGROUND From a classical point of view, gastric motility acts to clear the stomach between meals, whereas postprandial motility acts to provide a reservoir for food, mixing and grinding the food and to assure a controlled flow of food to the intestines. AIM: To summarise findings that support the role of gastric motility as a central mediator of hunger, satiation and satiety. METHODS A literature review using the search terms 'satiety', 'satiation' and 'food intake' was combined with specific terms corresponding to the sequence of events during and after food intake. RESULTS During food intake, when gastric emptying of especially solids is limited, gastric distension and gastric accommodation play an important function in the regulation of satiation. After food intake, when the stomach gradually empties, the role of gastric distension in the determination of appetite decreases and the focus will shift to gastric emptying and intestinal exposure of the nutrients. Finally, we have discussed the role of the empty stomach and the migrating motor complex in the regulation of hunger signals. CONCLUSIONS Our findings indicate that gastric motility is a key mediator of hunger, satiation and satiety. More specifically, gastric accommodation and gastric emptying play important roles in the regulation of gastric (dis)tension and intestinal exposure of nutrients and hence control satiation and satiety. Correlations between gastric accommodation, gastric emptying and body weight indicate that gastric motility can also play a role in the long-term regulation of body weight.