An orchestrated function of all these components is required for the appropriate propulsive movement of the food in the gastrointestinal tract.
Gastroparesis, a pathological slowing-down of gastric emptying, is a result of the damage to the tissue elements involved in the regulation of motility. Gastroparesis is one of the well-known complications of longstanding diabetes mellitus.
Although it is rarely a lifethreatening complication, it has a deteriorating effect on the quality of life, leads to unpredictable oscillation of the blood glucose level, and increases the time required for the absorption of food and medicines. This review describes the clinical characteristics of diabetic gastroparesis and summarizes the organic and functional motility abnormalities caused by this This article is part of the Topical Collection on Microvascular Complications—Neuropathy V.
Kempler e-mail: kempler.
Megjelenés éve: Kivonat: The regulation of gastrointestinal motility mainly involves the smooth muscle, neural extrinsic and intrinsicand hormonal elements, the glial cells, and the interstitial cells of Cajal. An orchestrated function of all these components is required for the appropriate propulsive movement of the food in the gastrointestinal tract. Gastroparesis, a pathological slowing-down of gastric emptying, is a result of the damage to the tissue elements involved in the regulation of motility. Gastroparesis is one of the well-known complications of long-standing diabetes mellitus. Although it is rarely a life-threatening complication, it has a deteriorating effect on the quality of life, leads to unpredictable oscillation of the blood glucose level, and increases the time required for the absorption of food and medicines.
Lengyel : T. Várkonyi 1st. Lengyel e-mail: lecs in1st. Várkonyi e-mail: varkonyitamas gmail. Finally, the currently available and potential future therapeutic approaches are summarized. Keywords Diabetes mellitus.
Interstitial cells of Cajal. Neural elements.
Furthermore, a normal gastric motility rate does not exclude the possibility that the complaints originate from motility disorders, while a slower gastric motility is not always associated with symptoms . It is important to emphasize that the only manifestation of gastroparesis in some patients without GI symptoms is poor glycemic control, whereas in other cases, the completely opposite phenomenon may be experienced: the presence of obvious symptoms are not related to dysglycemia . Due to delayed food absorption, postprandial hypoglycemia might be a characteristic feature of gastroparesis among insulin-treated diabetic patients.
Although slower stomach emptying in a case of long-standing diabetes mellitus rarely leads to life-threatening complications and does not increase mortality , it increases the risk of an electrolyte imbalance, as well as hypo- or hyperglycemia. Gastroparesis should also be considered as the underlying mechanism among patients thought to have brittle diabetes.
As in various other areas of medicine, the severity of the disease may be characterized by different scoring systems. Further investigations are required to test whether these questionnaires are sufficiently valuable to guide the proper therapeutic approach or how well diabetic gastroparesis diagnosis scores lead to an estimate of the prognosis of the gastric complication. The mixing and the propulsive movement of liquid and solid food arriving into the esophagus and the lower parts of the gastrointestinal GI tract diabetic gastroparesis diagnosis the well-coordinated work of five basic tissue elements: smooth muscle, extrinsic and intrinsic neurons, glial cells, hormonal elements, and the interstitial cells of Cajal ICCs.
Damage to any of these elements leading to an imbalance of the neuromuscular unit will deteriorate the propulsive movement of food to some extent.
The degrees to which these elements are involved determine the degree and nature of the functional disorder. The stomach, positioned in the upper tract of the GI system, has a unique role in the processing of food, since it accommodates to the volume of the aliments, stores them, grinds them into small pieces, and transmits the food toward the duodenum. Under physiological conditions, the movement of low-calory liquid food, especially water, toward the duodenum depends on its volume and the pressure pump function of the stomach .
Low-calory solid food such as bread spends 20—30 min in the stomach, while a continuous peristaltic movement starts at the mid-upper corpus of the greater curvature of the stomach, spreads toward the antral region usually 3—5 times per minute , and presses the pieces of food colpit a cukorbetegség kezelésének the almost closed pylorus.
This way, the stomach comminutes the solid food and makes it accessible to the digestive enzymes. Hyperosmotic, acidic, or nutrient-rich food makes stomach emptying much slower .
The over-slow emptying of solid food from the stomach for a nonmechanical reason is defined as gastroparesis . Gastroparesis was one of the first complications of diabetes described , and some ancient doctors, such as Aretaeus of Cappadocia, thought that diabetes was a disease of the stomach. The etiology of gastroparesis cannot be identified in about a third of the cases . The symptoms in all cases are chronic and recur frequently , including epigastric burning sensation, bloating, early satiety, abdominal discomfort, nausea, and vomiting.
Diabetic gastroparesis occurs more diabetic gastroparesis diagnosis in women, in obese patients with poor glycemic control, and in patients where other complications of diabetes have already appeared.
Nonetheless, an obvious relationship between the higher glycated hemoglobin HbA1c level and the development and severity of gastroparesis has not been clearly established . The connection between symptoms and motility disorders related to gastroparesis is diabetic gastroparesis diagnosis poor [17, 18].
An increased rate of stomach emptying is a characteristic finding in patients with a relatively short diabetes history less than 2 years and without the signs and symptoms of diabetic neuropathy . Faster than normal stomach emptying can be observed even in long-term type 1 diabetes mellitus . In animal models, insulin therapy in a subtherapeutic dosage normalized increased stomach emptying .
The most important consequence of faster gastric emptying in clinical practice is sudden postprandial hyperglycemia shortly following food intake. It is also possible that this increased rate of stomach emptying is a preliminary phase of later slower stomach emptying . Diabetic gastroparesis involves a severe delay of stomach emptying of both solid and liquid food .
In a survey, type 2 diabetic patients with delayed emptying were older, had higher body mass index, and exhibited more intensive nausea and early satiety, as compared with type 1 diabetic patients Curr Diab Rep with impaired gastric motility . Several functional changes can be found in the background of slower stomach emptying [21—24]. However, acute and chronic hyperglycemia have different effects on stomach motility. In healthy volunteers, severe artificial hyperglycemia causes slowing-down of the emptying of nutrient-containing liquid and solid food .
In type 1 diabetic patients with diabetic autonomic neuropathy, hyperglycemia increases the frequency of rhythmic activity in the stomach, resulting in tachygastria . Obvious deleterious effects of hyperglycemia cannot be confirmed on ICCs cells generate and propagate electrical activity in the stomach and the GI tract . Interestingly, in type 1 diabetic folk kezelési módszerek 2 típusú diabetes mellitus without autonomic neuropathy, the stomach emptying can be significantly decreased even if the postprandial blood glucose elevation does not exceed the physiological range .
Chronic hyperglycemia in diabetes can also be responsible for all of the above-mentioned diabetic gastroparesis diagnosis disorders. However, it is important to consider that diabetes is associated not only with elevated blood glucose levels, but additionally with an absolute or relative absence of insulin. The importance of this phenomenon is revealed by in vitro experimental data demonstrating the deteriorating effect of the absolute absence of insulin on stomach ICCs and the smooth muscle cells .
In general, slower movement of diabetic gastroparesis diagnosis food from the stomach in diabetes is more frequent than slower movement of liquids. The impaired pyloric pressure pump function also has an effect on solid food emptying , and the dilatation of the distal stomach also relates to the antral hypomotility .
It is probably important that the slow waves of the stomach generated by the ICCs are modified by a number of factors, such as the sympathetic—parasympathetic balance, eating, and medicines. Any disturbance in these factors can worsen the effectivity of the peristalsis .
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The reasons for the discrepancy between the symptoms and detectable motility disorders are not clear; a possible explanation is the viscero-sensory functional defect related to diabetic autonomic neuropathy.
The increased activity or sensitivity of these neuronal systems in the proximal stomach might explain the generation of nausea, vomiting, early diabetic gastroparesis diagnosis, and epigastrial pain experienced in type 1 diabetic patients without substantial motility disorders .
Various factors can damage different tissues, including hyperglycemia and an absolute or Page 3 of 9, relative lack of insulin. The increase in mitochondrial superoxide activity caused by the increased glucose diabetic gastroparesis diagnosis can be an important factor in the development of chronic morphologic complications of diabetes .
The increased oxidative stress-related decrease in nitric oxide NO concentration, together with the reduced activity of heme oxygenase, is an important feature of the pathogenetic background at the cellular level .
Carbon monoxide produced by heme oxygenase has a protective effect on the ICCs . Histological changes in long-standing diabetes can also be studied. In a human investigation in antrum samples, mild lymphocytic infiltration in the myenteric plexus was a characteristic finding of diabetic gastroparesis . Significant reductions in the numbers of neuronal elements and the ICCs in the antrum wall were detected .
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In diabetic gastroparesis diagnosis investigation, the loss of neuronal elements was proven in diabetic samples from the mucosal layer . In a larger study , the most frequent abnormality was damage to or loss of the ICCs and the decrease in the number of NO synthase NOS positive neurons. However, the loss of the NOS-positive neurons was more characteristic for idiopathic gastroparesis.
Electromicroscopic investigations detected a significant increase in the amount of connective tissue. Overall, the most characteristic histopathological change in diabetic gastroparesis is the loss of or damage to the ICCs. The pathophysiologic steps leading to ICC damage are complex.
The ICCs are very sensitive to the lack of insulin, despite the absence of insulin receptors and insulin-like growth factor-1 IGF-1 receptors on these cells .
The explanation of this paradoxical situation was provided by experiments  that revealed that the smooth muscle cells of the stomach have insulin and IGF-1 receptors and these cells produce the stem cell factor SCF that is essential for the development and maintenance of the network of Cukorbeteg fogyaszthat e mézet. The smooth muscle atrophy that develops in the lack of insulin is responsible for the decreased production of SCF and, hence, for the damage to the ICC network [27, 40].
The exact mechanism of ICC damage is still not clear, and several questions diabetic gastroparesis diagnosis to be answered [42, 43]. The most characteristic scarlet diabétesz kezelésére szolgáló findings and symptoms of diabetic gastroparesis are listed in Tables 1 and 2. The parasympathetic regulation can exert both excitatory and inhibitory effects, while the sympathetic input is generally inhibitory, with the exception of its propulsive influence on the lower esophageal sphincter .
Diabetic Gastroparesis: Functional/Morphologic Background, Diagnosis, and Treatment Options
In accordance with the previous description, GI autonomic neuropathy is the result of a complex pathophysiological process that involves organic and functional impairments of the neuronal cells and a progressive imbalance of various autonomic regulations. The changes include reduced numbers of ICCs, extrinsic autonomic neurons, and smooth muscle cells with altered inhibitory neurotransmission . In patients with diabetic gastroparesis, a reduction in the intraneuronal levels of NO has also been observed .
It is assumed that the leading pathophysiologic abnormality is the impairment of parasympathetic function in autonomic neuropathy. Sham feedinginduced gastric acid production or pancreatic polypeptide response to hypoglycemia is decreased in diabetic patients as well. Since both the gastric secretory function and pancreatic polypeptide secretion are under vagal control, these observations support the role of parasympathetic damage in the development of diabetic gastroparesis [46, 47].
The progression of the impaired gastric emptying seems to be slower than the progression of the autonomic neuropathy . Besides the chronic metabolic exposure, acute hyperglycemia can also alter GI vagal functions .
Moreover, current hyperglycemia affects parasympathetic cardiac functions even in healthy subjects, pointing to the importance of the physiological condition of all those factors that possibly affect diabetic gastroparesis diagnosis vagal control in the regulation of gastric emptying .
The emptying of the stomach might Curr Diab Rep be slower when the balance between the excitatory diabetic gastroparesis diagnosis inhibitory regulations of the autonomic system becomes disturbed . Parasympathetic function becomes abnormal earlier during the progression of autonomic neuropathy than does the sympathetic function, leading to weakening of the excitatory parasympathetic innervation of the stomach and a relative strengthening of the inhibitory sympathetic effects .
The alteration in the sympathetic function can also have detrimental effect on gastric emptying. Several important processes are regulated by the sympathetic nervous system, which may also partially affect the gastric motility visceral reflexes, nausea, vomiting, and abdominal pain.
A gastroparesis és kezelésének lehetőségei
Despite the well-known general consequences of the parasympathetic and sympathetic impairments, it is still not clear how these alterations act directly on the motility of the stomach in diabetic patients. Besides the normal extrinsic autonomic neuronal functions, intact central neuronal regulation is also mandatory for the integrity of gastric emptying. Abnormal visceral hypersensitivity as a result of an altered afferent central function is a newly documented source of various digestive symptoms that are responsible for an impaired quality of life .
Mit lehet megvásárolni a cukorbetegségű teaért 2. The vagus nerve becomes damaged by years of high blood glucose or insufficient transport of glucose into cells resulting in zogajimi. Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. It often occurs in people with type 1 diabetes or type 2 diabetes.
In line with this, a recent study demonstrated altered central sensory processing in diabetic patients with upper abdominal symptoms . A few clinical observations suggest the role of the central neuronal system in the regulation of certain visceral functions, including gastric motility . The severity of the autonomic neuronal damage in humans is not yet measurable directly; therefore, reproducible and sensitive cardiovascular and sensory tests are applied to estimate the neuronal dysfunctions in patients with abnormal gastric emptying or GI méz kezelés diabetes mellitus 2 típusok. In some of these tests, correlations have been found between neuropathy and stomach motility.
The overall autonomic neuropathy score calculated from cardiovascular reflex tests correlated positively with the scintigraphic gastric emptying rate of solids in patients with long-standing type 1 diabetic patients .
Two heart rate tests of the five cardiovascular tests consistently correlated with the emptying of an isotope-labeled solid meal from the stomach in long-standing type 1 diabetes . These heart rate tests, the heart rate response to deep breathing, and the Valsalva maneuver are regarded as sensitive indicators of the parasympathetic function that become cukor cukorbetegség halus kezelés during the early course of neuropathy.
These data support the hypothesis that the insufficiency of the excitatory effect of the vagal nerve on the postprandial phase of the stomach functions leads to delayed emptying in type 1 diabetic patients with long duration. Reduced heart rate variability, a well-known indicator of the autonomic dysfunction, was associated with GI complaints in diabetic patients with sensorimotor neuropathy, suggesting a concomitant role of various manifestations of neuropathy in diabetic gastroparesis diagnosis pathogenesis of digestive complications .
Although several studies have documented correlations between neuropathy tests and gastric emptying, numerous Curr Diab Rep other studies did not discern any relationship . This might be explained in terms of the restricted methodology of the measurement of the complex GI neuronal dysfunctions, the heterogeneity of the tests applied in the various studies, and the importance of pathophysiological factors other than neuropathy in the pathogenesis of gastroparesis.
The Role of Nitric Oxide Synthase in the Development of Diabetic Gastroparesis The NOS-positive neurons identified in the GI tract have a crucial role in the inhibitory regulation of the motility functions and, hence, in the relaxation of the diabetic gastroparesis diagnosis sphincters.
It has been confirmed in animal models that inhibition of neuronal NOS results in slower stomach emptying.
Human investigations have revealed tészta cukorbetegeknek the endogenous NO inhibits the propulsive movement in the stomach . The clinical observation that diabetic gastroparesis predominantly affects women might be related to the fact that impairment of the nitrergic system is more pronounced in females . It has been revealed in animal models that the number of NOSpositive neurons decreases in diabetes and, in parallel with the loss of these neurons, the regulation of pyloric relaxation, just as the antral tone diabetic gastroparesis diagnosis.
Early treatment with insulin led to rearrangement of the presence of NOS-positive neurons and their synthetic function .
A possible future therapeutic approach may be to transplant stem cells that can differentiate into NOS-positive enteral neurons .
The Role of Enteral Hormones in the Development of Diabetic Gastroparesis The role of these hormones in the pathomechanism of diabetic gastroparesis is still controversial. The effects of the hormones that stimulate e. One of the most frequently investigated enteral hormone is GLP-1, since dipeptidyl-peptidase-IV inhibitors and GLP-1 analogues and agonists are increasingly more widely used in clinical practice.
The consequences of elevations or reductions of this peptide in diabetes have been analyzed, and an association was proven between the effect of GLP-1 on gastric emptying and the elevation of postprandial glucose levels . Ghrelin has also been a target molecule in recent investigations. Although in a species-specific manner, ghrelin promotes the antro-pyloric Page 5 of 9, coordination and can thereby improve stomach emptying [64, 65].
Ghrelin receptors diabetic gastroparesis diagnosis located in the highest concentrations on antral and duodenal neurons, with decreasing amounts toward the distal regions . Accordingly, it can be assumed that ghrelin has effects on vagal nerves , and the connection between neuropathy and enteral neurons is also indicated .
Összefoglalás A diabetes mellitus szövődményeként megjelenő tápcsatornai funkciózavarok közül a gyomorürülés zavara, a diabeteszes gastroparesis az egyik leggyakoribb kórkép. A gyomorürülési zavar mértéke eltérő lehet, s a klinikai tünetekkel való korrelációja nem egyértelmű. A kórképről rendelkezésre álló patogenetikai ismereteket, a kórképre utaló klinikai jellemzőket, a diagnosztika egyszerű és speciális eszközeit, a terápia mai lehetőségeit foglalja össze a közlemény. Kulcsszavak: diabetes mellitus, gastroparesis, diagnózis, terápia Diabetic gastroparesis: diagnosis and treatment Summary Functional disorders of the gastrointestinal tract are well known complications of the long standing diabetes mellitus. The impairement of the gastric emptying, as classified in the diabetic gastroparesis shows significant clinical importance because the lack of pronounced clinical symptoms in the majority of cases; the correlation is poor between symptoms and the delay of the gastric emptying in this pathology.
The multiple aspects of the effects of enteral hormones can be further exemplified by cukorbetegség kezelésére magyarországon fact that some of the enteral hormones GLP-1, peptide YY, and gastrin promote the survival of the pancreas beta cells, which can have a beneficial influence diabetic gastroparesis diagnosis GI function .
In view of the close anatomical and functional connection between enteric neurons and EGCs [70, 71], it can be assumed that damage to these cells plays an important role in the diabetes-related impairment of the enteric nervous system and, hence, in motility disorders.
However, this close neuron—glia connection complicates the separate in vivo investigation of these cells. Conditional ablation of the EGCs diabetic gastroparesis diagnosis changes in the neurochemical coding of enteric neurons, which may be responsible, in part, for the reduced gastric emptying and intestinal transit . In an in vitro study, viral targeted ablation of EGCs increased the level of diabetic gastroparesis diagnosis death in the presence of oxidative stress because the neuroprotective effects of the EGCs via their release of glutathione were missing .
Oxidative stress also activates mechanisms that result in glia-mediated inflammation that causes secondary neuronal damage . The complex role of EGCs in diabetes-related gastric motility disorders has not yet been clearly identified, but their potential targeted influence may open up new therapeutic approaches. Diagnosis Scintigraphic Gastric Emptying Procedure The standard method for the diagnosis of diabetic gastroparesis is the scintigraphic evaluation of stomach emptying.
Recent developments in ultrasonography make this technique too suitable for the evaluation and diagnosis of impaired gastric emptying. In clinical practice, when GI symptoms appear, patients should undergo routine gastroscopy, during which the possibility of slower stomach emptying may be suspected. The standardization of the scintigraphic measurement of stomach emptying has raised a number of questions, since numerous factors influence gastric emptying .
The rate of gastric emptying is frequently defined by using 99mTc-sulfurPage 6 of 9 colloid-containing eggs. During the procedure, the imaging is carried out at minute intervals while the patient is lying in supine position.