Nutrient malassimilation after total gastrectomy and possible intervention.

Lactulose Breath Test to Assess Oro-cecal Transit Delay and Estimate Esophageal Dysmotility in Scleroderma Patients

<h3>Background</h3> Microscopic colitis (MC) remains an elusive cause of chronic diarrhea. Histopathology is a gold standard with variable yield. The OCTT and concomitant lactose intolerance in these cases may aid to understand the complex symptoms. We used Hydrogen(H2) breath tests (H₂BT) for detecting SIBO (Small Intestinal Bacterial Overgrowth), Lactose intolerance and calculation of oro-cecal transit time (OCTT). <h3>Methods</h3> 43 MC patients [mean age - 45.83(±15.92] and 10 controls were studied. Among these, 37(86%) patients with MC &amp; 9 (90%) controls underwent breath tests. SIBO was diagnosed with glucose H₂BT. For confirmation, we took rise ≥12 ppm over fasting value in H2 concentration within 2hours of glucose ingestion Lactulose H₂BT was done to calculate OCTT. Time taken for rising in breath hydrogen by ≥12ppm over baseline value in two consecutive readings was considered as OCTT. For lactose breath test, 15 minutes samples were taken up to 4 hours. A ≥20 ppm rise over fasting value in H₂concentration in two consecutive readings was considered intolerance <h3>Results</h3> Four(9.5%) patients of SIBO in Glucose H₂BT were enrolled in controls. Mean (+ SD) OCTT in cases of MC vs controls was 130.38±47.95 mins and 97.14±48.55 mins (p= 0.109) respectively. Thus OCTT increased in 73% cases of MC vs 43% controls. Also, in the MC group, 9(28.1%) patients were lactose intolerant while vs 3(42.9%) controls (p= 0.654). Thus a significant 28% MC patients were lactose intolerant possibly aggravating symptoms <h3>Conclusions</h3> Lactose intolerance has lesser prevalence in cases of microscopic colitis. These patients were also detected to have paradoxically prolonged OCTT excluding the role of small bowel in diarrheal symptoms

After the skin, the gastrointestinal tract is the second most common target of systemic sclerosis (SSc). Our aims were to investigate orocecal transit time (OCTT) and the presence of small intestinal bacterial overgrowth (SIBO) in SSc as a cause of intestinal symptoms. Fifty-five SSc patients and 60 healthy controls, sex and age matched, entered the study. Enrolled subjects completed a questionnaire for intestinal symptoms and a global symptomatic score (GSS) was calculated. OCTT and the presence of SIBO were assessed by a lactulose breath test (LBT). Patients with SIBO were treated with rifaximin 1,200 mg/day for 10 days. Finally, a second questionnaire and LBT were performed 1 month after the end of therapy. The prevalence of SIBO was higher in SSc patients compared with controls (30/54 vs 4/60, respectively, P < 0.001). OCTT was significantly slower in SSc patients compared with controls (150 min, 25-75th percentile 142.5-165 vs 105 min, 25-75th percentile 90-135, respectively, P < 0.001). In patients with SIBO, the median GSS score was 8 (25-75th percentile 3.25-10.75). Eradication of SIBO was achieved in 73.3% of patients, with a significant reduction of symptoms in 72.7% of them (GSS score 2, 25-75th percentile 1-3, P < 0.05). These data suggest that SIBO occurs more frequently in SSc patients than in controls. Intestinal symptoms in these patients may be related to this syndrome and its eradication seems useful to improve clinical features. OCTT is significantly delayed in SSc patients, suggesting an impairment of intestinal motility, a further risk factor for the development of SIBO.

Long-term treatment with cisapride and antibiotics in liver cirrhosis: effect on small intestinal motility, bacterial overgrowth, and liver function

The 13C-acetate breath test (13C-ABT) allows noninasive measurement of liquid gastric emptying time (LGET), the H2-lactulose breath (H2-LBT) measures orocecal transit time (OCTT). Because of different test principles, both tests can generally be combined. This would not only spare time and resources but may also deliver additional information on the integrated regulation of gastrointestinal motor functions. Our aim was to define an adequate test protocol and to generate normal values for the combined 13C-ABT/H2-LBT. Twenty two healthy volunteers participated (HV, 12 females, age: 26.5 ± 4.7 years, BMI: 22 ± 2.1 kg m−2). Fasting subjects received 200 ml of an aequous solution containing 150 mg 13C-acetate and 10 g lactulose. Breath samples for H2 measurements were collected before ingestion of the test solution and afterwards at 5 min intervals for 180 min, for 13C measurements sampling intervals were prolonged to 15 min after the first hour. LGET was defined as time of maximal 13C-exhalation, OCTT as increase in H2 of ⩾ 20 ppm above basal. Small bowel transit time (SBTT) was calculated as the difference between OCTT and LGET. Mean [95% CI] values for LGET, OCTT and SBTT were 26 [23–30] min, 85 [68–102] min and 60 [44–76] min, respectively. Normal values for LGET and OCTT corresponded with published data. SBTT was not correlated with LGET (R2 = 0.019; p = 0.546). By contrast, there was a very tight and highly significant correlation between SBTT and OCTT (R2 = 0.933; p < 0.001). Multivariate linear regression analyses confirmed that age, sex and BMI had no significant effects on OCTT or SBTT while LGET was weakly correlated with BMI (R2 = 0.240; p = 0.021). In conclusion, the combined 13C-ABT/H2-LBT allows simultaneous measurement of LGET and OCTT as well as calculation of SBTT.

Probiotics Prevent Hepatic Encephalopathy in Patients With Cirrhosis: A Randomized Controlled Trial

Increased oro-cecal transit time in grade I or II hepatic encephalopathy

Type 2 diabetes mellitus consists of dysfunctions characterized by hyperglycemia and resulting from combination of resistance to insulin action and inadequate insulin secretion. Most of diabetic patients report significant gastrointestinal symptoms. Entire GI tract can be affected by diabetes from oral cavity to large bowel and anorectal region. Proteins, carbohydrates, fats, and most fluids are absorbed in small intestine. Malabsorption may occurs when proper absorption of nutrients does not take place due to bacterial overgrowth or altered gut motility. The present study was planned to measure various malabsorption parameters in type 2 diabetic patients. 175 patients and 175 age and sex matched healthy controls attending Endocrinology Clinic in PGI, Chandigarh were enrolled. Lactose intolerance was measured by using non-invasive lactose hydrogen breath test. Urinary d-xylose and fecal fat were estimated using standard methods. Orocecal transit time and small intestinal bacterial overgrowth were measured using non-invasive lactulose and glucose breath test respectively. Out of 175 diabetic patients enrolled, 87 were males while among 175 healthy subjects 88 were males. SIBO was observed in 14.8% type 2 diabetic patients and in 2.8% of controls. There was statistically significant increase (p<0.002) in OCTT in type 2 diabetic patients compared with controls. OCTT was observed to be more delayed (p<0.003) in patients who were found to have SIBO than in patients without SIBO. Lactose intolerance was observed in 60% diabetic patients and 39.4% in controls. Urinary d-xylose levels were also lower in case of diabetic patients but no significant difference was found in 72h fecal fat excretion among diabetic patients and controls. Urinary d-xylose and lactose intolerance in SIBO positive type 2 diabetic patients was more severe as compared to SIBO negative diabetic patients. From this study we can conclude that delayed OCTT may have led to SIBO which may have instigated the process of malabsorption among type 2 diabetic patients.

AimThe aim of the study was to determine the efficacy of prokinetic agents in diabetic gastroparesis patients.MethodThis was a randomized open-label trial conducted on 50 patients with type 2 diabetes experiencing diabetic gastroparesis, which was diagnosed with the lactulose hydrogen breath test. After randomization, all 50 patients were divided into four arms (cinitapride, metoclopramide, levosulpiride, and domperidone) of different prokinetics and followed up for four weeks; after which, repeat gastroparesis cardinal symptom index score and orocecal transit time were recorded in order to assess the response to the treatment.ResultThere was no statistically significant difference among the four groups in terms of all the baseline characteristics except for gender (p=0.032). The follow-up gastroparesis cardinal symptom index was collected for 50 patients but repeat orocecal transit time could be performed only in 37 patients. In all four groups, there was a statistically significant (p<0.05) improvement in terms of orocecal transit time and gastroparesis cardinal symptom index scores. But there was no statistically significant difference in relative efficacy amongst these study groups.ConclusionOur study showed statistically significant improvement with four prokinetics drugs in terms of gastroparesis cardinal symptom index score and orocecal transit time, but there was no statistically significant benefit of one prokinetic drug over the other. Our study showed promising results with regard to prokinetic use in diabetic gastroparesis.

Deranged intestinal motility, which occurs in cirrhosis, may facilitate the development of intestinal bacterial overgrowth (IBO), which can lead to bacterial translocation (BT). To assess the effect of cisapride on IBO and BT in cirrhosis, cirrhotic rats received cisapride or a placebo for 7 days, and measurements of jejunal bacterial content and BT studies were performed. In addition, jejunal fluid from 46 cirrhotic patients was obtained for quantitative bacterial culture. Those patients in whom gram-negative IBO was detected were randomized to receive or not to receive cisapride (20 mg twice per day) for 1 week. Cisapride significantly reduced IBO in cirrhotic rats. In addition, no BT was documented in treated animals, whereas it occurred in 40% in nontreated cirrhotic rats. Total IBO was documented in 23 of 46 cirrhotic patients, which was caused by gram-negative organisms in 10 cases. Orocecal transit time (OCT) significantly decreased after cisapride therapy, and was associated with the abolishment of bacterial overgrowth caused by gram-negative organisms in 4 out of 5 treated patients, whereas it persisted in nontreated cases. Cisapride administration to cirrhotic rats resulted in a reduction of the IBO, which is associated with a marked decrease in BT. On the other hand, cisapride facilitates the abolition of IBO caused by gram-negative organisms in cirrhotic patients.

The mechanisms by which dietary fiber exerts its laxative action are not fully understood. Finely grinding wheat bran reduces its effect. Inert plastic particles are equipotent to bran if they consist of flakes or sliced tubing. It is not known whether altering the size or shape of inert particles alters their effect on intestinal function. In a randomized crossover study, 18 volunteers swallowed 24 g/day of plastic as branlike flakes or as small granules for 10-12 days with a two-week washout period between interventions. Whole-gut transit time (WGTT), orocecal transit time (OCTT), defecation frequency, stool form, stool water content, stool pH, and dietary intake were assessed. The plastic flakes caused a 24% (P < 0.001) reduction in WGTT and a 19% (P = 0.002) fall in OCTT. Resultant and appropriate changes in stool form, interdefecatory intervals (IDI), and stool weight were seen. The small granules did not cause any significant change in WGTT or OCTT, although IDI did decrease and stool output and stool form score increased. The stimulant effect of solid particles in the intestinal lumen upon transit time is influenced by the morphology of the particles.

Relation between gastric emptying and small bowel transit in normal subjects studied with breath tests

BackgroundThe efficacy of sacral nerve stimulation (SNS) on patients with chronic refractory slow-transit constipation is controversial and its mechanism of action on gastrointestinal motility and transit is not fully understood. The aim of this study was to document the effects of temporary SNS on the gastrointestinal and biliary tract motility and on gastrointestinal transit in patients with refractory slow-transit constipation.MethodsThis was a prospective interventional study. Patients with slow-transit chronic constipation, unresponsive to any conservative treatment, were enrolled between January 2013 and December 2018. Patients’ quality of life [patient assessment of constipation quality of life (PAC-QOL) questionnaire], constipation scores (Cleveland Clinic Constipation Score) colonic transit time (CTT), orocecal transit time (OCTT), gastric and gallbladder kinetics, together with the assessment of the autonomic nerve function were evaluated before and during temporary SNS.Results14 patients (12 females, median age 38 years, range 24–42 years) had temporary SNS. The Cleveland Clinic Constipation Score did not change compared to baseline (23 ± 3 vs 21.4; p = 070). The PAC-QOL did not improve significantly during the stimulation period. Gallbladder/stomach motility (half-emptying time) did not change significantly before and after SNS. OCTT was delayed at baseline, as compared to standard internal normal values, and did not change during SNS. CTT did not improve significantly, although in two patients it decreased substantially from 97 to 53 h, and from 100 to 65 h.ConclusionsTemporary SNS did not have any effect on upper/lower gastrointestinal motility and transit in patients with severe constipation.

It is well accepted that long-term administration of opioids results in a dose-related constipation. No data so far have demonstrated conclusively whether such constipation is also seen after intake of a controlled release formulation. It was therefore of interest to evaluate whether increasing doses of a controlled release formulation of dihydrocodeine (DHC, CAS 125-28-0) after oral administration also induces a dose-related increase in constipation. Additionally, it was of interest to study whether such a peripheral opioid-related side effect is also seen in another, central receptor-mediated effect, the constriction of the pupil, at clinically relevant doses. Twelve volunteers were given controlled release DHC (60 and 120 mg, respectively) or placebo orally within a randomized, double-blind cross-over study. In order to determine the degree of constipation, oro-cecal transit time was measured using the H2-exhalation test. Additionally, in order to evaluate a centrally mediated effect, the response of the pupil to light was quantified using the pupillary light reflex technique. Both, peripherally and centrally mediated effects were compared to placebo. DHC at both dosages induced a significant (p < 0.01) prolongation of oro-cecal transit time when compared to placebo. However, prolongation of oro-cecal transit was not significantly longer when comparing the lower (60 mg) with the higher dose (120 mg). DHC also induced a significant (p < 0.005) depression of the pupillary light reflex from 53.9 mm (control) to 8.3 and 7.4 mm, respectively. Similar to intestinal transit, the pupillary light reflex was not significantly different among the two doses of DHC. Also, both dosages induced a similar amount of side effects. Tiredness and dry mouth were reported in 80% after both doses while vertigo was reported in 5% and 1% complained of headache. None of the volunteers reported nausea or emesis. It is concluded that opioid receptor sites, which are located in the plexus myentericus of the intestinal wall, are responsible for the delay in propulsion. Because of the controlled release of a fixed amount of DHC over time there is constant binding of the ligand followed by a constant conformational change of peripheral and central receptor sites. Thus constant release induces no dose-related increase in oro-cecal transit and inhibition of the pupillary light reflex.

This study comprises 39 patients with duodenal ulcer, 113 patients with partial gastrectomy, 9 with total gastrectomy and 6 patients with gastroenterostomy. After ingestion of a standard meal the intestinal contents were collected during 4 subsequent periods of 20 minutes each. The volume, pH, and the concentrations of alpha-amylase, trypsin, chymotrypsin, and lipase in the collections were determined. The pH was not below normal in patients with duodenal ulcer. The results indicated an admixture of salivary to pancreatic amylase in the intestine of patients with gastrojejunostomy, especially by concomitant hypochlorhydria. In all groups of patients, secretions of trypsin and chymotrypsin were closely related. In patients with partial or total gastrectomy, the secretion of lipase was more markedly reduced than the secretion of the other enzymes. The mean concentration of lipase in the efferent loop in Billroth II patients was found to be closely related to the fat absorption. Depending on the enzyme concerned, 10-20 per cent of the patients with duodenal ulcer, and 21-50 per cent of the patients subjected to Billroth II gastrectomy had abnormally low concentrations of enzymes in all collections. In these groups of patients, the mean concentration of the four enzymes was significantly reduced in all collections. In patients exposed to Billroth I gastrectomy, gastroenterostomy, or total gastrectomy, mean concentrations of the enzymes were below normal levels in collection I only.