· Identify the common causes of gastroparesis in CKD · Overview of gut physiology
· Differentiate gastroparesis vs. other GI issues and their symptoms "· Provide comparison of gastroparesis & other common GI issues in CKD
· Testing and findings"
· Compare and contrast various evidence-based treatments for gastroparesis "· Review efficacy of current treatments in CKD for gastroparesis
· Cite what providers can safely advise patients to reduce symptoms"
Irritable Bowel Syndrome: An Update in Pathophysiology and Management Monkez M Yousif
Irritable bowel syndrome is the commonest health problem in hospital outpatient clinics and in private health care facilities and represents a big challenge for patients and physicians. This presentation discusses a different aspect of the disease from pathophysiology, clinical presentation and management
RECENT ADVANCES IN THE MANAGEMENT OF INFLAMMATORY BOWEL DISEASEPARUL UNIVERSITY
Medical treatment for inflammatory bowel disease (IBD) has progressed significantly over the past decade to achieve and maintain clinical remission in patients & to overcome the side effects of existing drugs for IBD. Conventional therapy for IBD include the use of Amino salicylates, corticosteroids & Anti-microbials. Patients who fail to respond to the conventional therapy are treated with agents such as Calcineurin inhibitor (Cyclosporine), and Biologics like TNF-α inhibitors (Infliximab or Adalimumab) or Anti-cell adhesion molecules (Vedolizumab, natalizumab). These agents are targeted against pro-inflammatory cytokines such as Tumor Necrosis Factor-α (TNF-α), Interleukin-2 (IL-2) and Cell Surface Adhesion Molecules Integrin α4β7. In this review, we provide an overview on the recent advances in the treatment for IBD such as newer Biologics, Small Molecule drugs and Biosimilars effective for IBD and the role of other therapies like Probiotics, Prebiotics, Stem cell transplant and Faecal microbiota transplant and Microbiome targeting diet in the management of IBD
Irritable Bowel Syndrome: An Update in Pathophysiology and Management Monkez M Yousif
Irritable bowel syndrome is the commonest health problem in hospital outpatient clinics and in private health care facilities and represents a big challenge for patients and physicians. This presentation discusses a different aspect of the disease from pathophysiology, clinical presentation and management
RECENT ADVANCES IN THE MANAGEMENT OF INFLAMMATORY BOWEL DISEASEPARUL UNIVERSITY
Medical treatment for inflammatory bowel disease (IBD) has progressed significantly over the past decade to achieve and maintain clinical remission in patients & to overcome the side effects of existing drugs for IBD. Conventional therapy for IBD include the use of Amino salicylates, corticosteroids & Anti-microbials. Patients who fail to respond to the conventional therapy are treated with agents such as Calcineurin inhibitor (Cyclosporine), and Biologics like TNF-α inhibitors (Infliximab or Adalimumab) or Anti-cell adhesion molecules (Vedolizumab, natalizumab). These agents are targeted against pro-inflammatory cytokines such as Tumor Necrosis Factor-α (TNF-α), Interleukin-2 (IL-2) and Cell Surface Adhesion Molecules Integrin α4β7. In this review, we provide an overview on the recent advances in the treatment for IBD such as newer Biologics, Small Molecule drugs and Biosimilars effective for IBD and the role of other therapies like Probiotics, Prebiotics, Stem cell transplant and Faecal microbiota transplant and Microbiome targeting diet in the management of IBD
Constipation is the symptom and is associated with primary & Secondary causes. Constipation is defined as occurrence of >3 episodes of bowel movements. the Rome III criteria defines the objective classification and bristol stool chart helps in assessing the type of stools passed. Management of constipation deals with early assess, treating the cause, adjuvant management, Pharmacological Management (laxatives, suppositories & enemas) and following constipation prevention bundle.
Constipation is the symptom and is associated with primary & Secondary causes. Constipation is defined as occurrence of >3 episodes of bowel movements. the Rome III criteria defines the objective classification and bristol stool chart helps in assessing the type of stools passed. Management of constipation deals with early assess, treating the cause, adjuvant management, Pharmacological Management (laxatives, suppositories & enemas) and following constipation prevention bundle.
Effects of diabetes on gastrointestinal systemhealthuseful
complications of diabetes that affect the digestive system, including gastroparesis, delayed stomach emptying, constipation, diarrhoea, and other digestive issues. These Effects of diabetes on gastrointestinal systeml and other health problems. Learn how diabetes affects the GI system, what symptoms to watch for, and how to manage these problems and prevent further complications.
Evaluation and management of patients with Dyspepsia.pptxgarvitnanecha
Evaluation and management of patients with Dyspepsia.
Dyspeptic symptoms.
Causes of dyspepsia
Approach to adult with Dyspepsia.
Newer advancement about diagnosing dyspepsia causes.
GERD and peptic ulcer and many more organic diseases.
Functional Dyspepsia and organic dyspepsia
CME Spark and the American Gastroenterological Association developed a Case Closed CME program for gastroenterologists and other healthcare providers involved in the care of patients with short bowel syndrome (SBS) to have a case-based learning experience that focuses on guidelines and best practices.
John K. DiBaise, MD
Professor of Medicine, Division of Gastroenterology and Hepatology
Mayo Clinic
Scottsdale, AZ
Understand principles of fluids, fluid compartments and composition
Identify role of kidneys in fluid management
Establishing Target Weight
Understand consequences of fluid overload
Assessing and implementing successful fluid overload management practices according to guidelines
Refeeding syndrome with Parenteral Nutrition in ESRDVishal Bagchi
After a sustained state of malnutrition or under-nutrition patients tend to exhibit symptoms of refeeding syndrome secondary to nutrition support received from oral or parenteral nutrition.
Define refeeding syndrome
Identify causes of refeeding syndrome with subjective and objective analysis
Acquire skills to manage refeeding syndrome during and after oral and/or parenteral nutrition support
Participants will be able to
Discuss the markers of malnutrition in CKD
Identify causes of malnutrition in CKD
Discuss current recommendations for treatment of malnutrition in CKD
Malnutrition in the Peritoneal Dialysis population is highly prevalent. This presentation will address the common problem and explore the many benefits of Intraperitoneal Nutrition (IPN) using research-based evidence
Discuss causes of malnutrition in Peritoneal Dialysis patients
Identify patients based on reimbursement criteria
Identify methods to overcome barriers to achieving optimum outcomes from IPN therapy
Ethics in nutrition and chronic kidney diseaseVishal Bagchi
Become familiar with the Scope of Practice for renal dietitians
Be able to define common terms related to medical ethics
Be able to recognize ethical dilemmas and gain the knowledge to deal with them appropriately
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. Disclaimer
Employee of Patient Care America
Non-FDA approved drugs are mentioned in this presentation
2
3. · Identify the common causes of
gastroparesis in CKD
· Overview of gut physiology
· Differentiate gastroparesis vs. other GI
issues and their symptoms
· Provide comparison of gastroparesis &
other common GI issues in CKD
· Testing and findings
· Compare and contrast various evidence-
based treatments for gastroparesis
· Review efficacy of current treatments in
CKD for gastroparesis
· Cite what providers can safely advise
patients to reduce symptoms
Objectives
3
4. History and Definition: Gastroparesis
Objective evidence of delayed gastric emptying in absence of obstruction
Symptoms: satiety, nausea, vomiting, bloating, and upper abdominal
discomfort.
It was first recognized as a complication of diabetes in 1945, and by 1958, the
term "gastroparesis diabeticorum" was commonly used to describe the
disorder.
The primary cause for diabetic gastroparesis is thought to be related to
autonomic neuropathy; however, virtually any disease or condition that can
cause neuromuscular dysfunction of the GI tract
4
Park MI, Camilleri M. Gastroparesis: clinical update. Am J Gastroenterol. 2006;101:1129-1139
5. Stomach: Anatomy and Physiology
Cardia and cardiac sphincter: prevents stomach contents
from going back up into the esophagus.
Body: Food is mixed and starts to break down.
Pylorus: includes the pyloric sphincter muscle that acts as
a valve to control the emptying of stomach contents
(chyme) into the duodenum
Bolus: Temporary storage held for 2 hours or longer
Churning and Hydrolysis
Pepsinogen + HCL = Pepsin
Chyme: thick, acidic, soupy mixture 2-4L
5
6. Symptoms Defined
Nausea: a subjective feeling of wanting to vomit, maybe referred
by patients as indigestion or being full. Global sensation
Vomiting: forceful expulsion of gastroduodenal contents
Regurgitation: effortless expulsion of esophageal or gastric
contents. Woke up middle of the night and was laying in vomit
Retching: abdominal muscle contractions with labored rhythmic
respiration. Nothing comes out
Rumination: effortless regurgitation of recently ingested food, re-
swallowing. Learned behavior
6
Images from Giphy
7. Etiologies of Gastroparesis
7
Idiopathic 36%
Diabetic 29%
Post-gastric surgery 13%
Parkinson's disease 7.5%
Collagen vascular disorders 4.8%
Intestinal pseudo-obstruction 4.1%
Miscellaneous causes 6%
Etiologies of Gastroparesis in 146 Patients Seen in 1 Tertiary Referral Series. Soykan I, Sivri B, Sarosiek I, et
al. Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term
follow-up of patients with gastroparesis. Dig Dis Sci. 1998;43:2398-2404.
8. Gastric Emptying Study
Standard: scintigraphy of solid phase meal
Discontinue medications affecting gastric emptying for 48-72 hours
Narcotics, anticholinergics delay emptying
Metoclopramide, domperidone, erythromycin accelerate emptying
Maintain normal glycemia
Patients consume a standard low-fat meal labeled with 99mTc- sulfur
colloid and are then imaged immediately after the meal is consumed, and
at 1, 2, and 4 hours
Results are reported as a percentage of gastric emptying at each time and
compared to validated standard values
Gastric emptying scintigraphy is available as an outpatient procedure only
Wireless motility capsule
Correlates 85% with T-90% emptying
13C octanoate breath tests
Intraduodenal administration of 20 ml normal saline containing 100 mg 13C-
octanoate and after ingestion of a 320-kcal muffin containing 100 mg 13C-octanoate
8
Article · Literature Review in European Journal of Clinical Investigation40(9):843-50 · September 2010 with 173 ReadsDOI: 10.1111/j.1365-2362.2010.02331.x · Source: PubMed
9. Normal Gastric Emptying Scintigraphy
9
J Neurogastroenterol Motil. 2011 Apr; 17(2): 189–191. Published online 2011 Apr 27. doi: 10.5056/jnm.2011.17.2.189
11. Varied Gastric Emptying Time with the
composition of the Meal
11
% Meal
remaining in
stomach
Lag phase Emptying phase
Time after meal (min)
Solid meal
Liquid meal
100
75
50
25
0
200 6040 10080
Semisolid
meal
13. CKD Meds and Gastric Motility
• Sevelamer is contraindicated in patients with bowel obstruction.
• Considering that approximately two thirds of dialysis patients have some
degree of dyspepsia-like symptoms, much of which may be related to overt
or subclinical gastroparesis, these are important concerns.
• For example, phosphate binding with calcium carbonate is optimal at a pH
of approximately 5 while calcium acetate is effective through a broader pH
range of 5 to 7
• This implies that calcium carbonate is most effective in the jejunum while
calcium acetate is effective in both the jejunum and ileum.
• Notably, neither agent is an effective phosphate binding agent at the low pH
expected in the stomach where phosphorus is more easily bound to
hydrogen than to calcium
13
15. Mechanism of Gastroparesis
*Not well studied but postulated
• Fundal Hypomotility
Different from fundoplication(Fundus stops working- Wrap the stomach
around the esophagus) done for anti reflux surgery
Solid phase delayed, liquid phase accelerated- Dumping Sx
• Antral Hypomotility
• Gastric arrhythmia
• Lack of coordination
15
16. Evaluation
Screen for:
Diabetes mellitus (especially uncontrolled glucose levels)
Thyroid dysfunction
Neurological disease
Prior gastric or bariatric surgery
Autoimmune disorders
Viral (post viral gastroparesis):
Symptoms may improve over time
Medication induced delay in gastric emptying:
Narcotics, GLP-1 and amylin analogs, cyclosporine
Confounding diagnoses:
Cyclic vomiting syndrome, cannabinoid hyperemesis
Rumination syndrome
Eating disorders
16
17. Dietary Management of
Gastroparesis
Small frequent (6/day) meals
Reduced fat (<40 gm/day)
Soup, crackers, noodles, pasta, potatoes,
rice, cheese
Reduced fiber helps avoid bezoar
a solid mass of indigestible material
that accumulates in your digestive tract,
sometimes causing a blockage
Liquid caloric supplementation
Glycemic control
17
Foods that are generally encouraged:
• Breads, cereals, crackers, ground or
pureed meats
• Vegetables – cooked and, if necessary,
blenderized/strained
• Fruits – cooked and, if necessary,
blenderized/strained
• Juices, beverages, milk products, if
tolerated
• Small, frequent meals
18. High Fiber Foods/Medications Associated with
Bezoar Formation – Avoid if possible
Legumes/Dried Beans
Bran /Whole Grain Cereals
Nuts and Seeds
Seeded Fruits
Dried fruits
Vegetables
Foods Associated with Bezoar Formation
Popcorn, Apples, Berries, Brussels sprouts,
Coconuts, Corn, Figs, Green beans, Legumes,
Oranges, Persimmons, Potato peels, Sauerkraut,
Tomato skins
High Fiber Medications/Bulking Agents
Acacia fiber; Benefiber®; Citrucel®;
FiberChoice®; Fibercon®; Konsyl®;
Metamucil®; Perdiem Fiber, or any psyllium
product
18
Carol Rees Parrish MS, RD and Nutrition Support Specialist University of Virginia Health and Jeanne Keith-Ferris, RN, BScN President/Founder, GPDA 5520 Dalhart Hill NW
Calgary, AB T3A 1S9 https://uvahealth.com/services/digestive-health/images-and-docs/gastroparesis-diet.pdf
19. Wytiaz V et al, Dig Dis Sci 2015;60:1052-8
Provoking versus Alleviating Foods
19
Acidic, fatty,
spicy, and
fiber-rich
foods provoke
symptoms
Bland, sweet,
salty, and
starchy foods
alleviate
symptoms
20. Dental Health
• Since gastroparesis impairs the stomach’s ability to mash
food and break it down into smaller sizes in preparation
for absorption, the chewing of food beforehand becomes
even more important.
• In addition, repeated exposure to stomach acid from
frequent vomiting may destroy tooth enamel.
• Remind patients to see their dentist regularly and take
good care of your teeth.
• Perimylolysis, a smooth erosion of the tooth enamel, is
common and manifests as a loss of enamel and
eventually dentin on the lingual surfaces of
the teeth caused by the chemical and mechanical effects
of chronic regurgitation of low-pH gastric contents and
movements of the tongue
20
21. Effect of dietary fat and food consistency on gastroparesis
symptoms in patients with gastroparesis
21
Homko CJ et al, Neurogastroenterol Motil 2015;27:501-8
22. Low-fat liquid meal had the least effect
Conclusions & Inferences
• A high-fat solid meal significantly increased overall symptoms among
individuals with gastroparesis, whereas a low-fat liquid meal had the least
effect.
• With respect to nausea, low-fat meals were better tolerated than high-fat
meals, and liquid meals were better tolerated than solid meals.
• These data provide support for recommendations that low-fat and increased
liquid content meals are best tolerated in patients with symptomatic
gastroparesis.
*Can be difficult for patients on fluid restriction with dialysis
22
Homko CJ et al, Neurogastroenterol Motil 2015;27:501-8
25. IDPN or IPN
Intradialytic Amino Acids, Dextrose and Fat infusion
80-120 gm Amino Acids (80-90% absorption)
20-60 gm Dextrose
20-40 gm lipids
800-1200 kcal
400-700 mL volume
1000-1400 mOsm/l
3-4 hour infusion time
Intraperitoneal Nutrition-
Replacement of Dextrose bag with Amino Acids
30-60 gm Amino Acids (~80% Absorption)
Patient Compliance Independent
25
26. Migrating motor complex (MMC)
Phase I – A prolonged period of
rest
Phase II – Increased frequency of
action potentials and smooth
muscle contractility;
Phase III – A few minutes of peak
electrical and mechanical activity,
and;
Phase IV – Declining activity which
merges with the next Phase I
26
28. Metoclopramide(Reglan) & Tardive
Dyskinesia
BLACK BOX WARNINGS: Metoclopramide can cause tardive dyskinesia (TD), a
potentially irreversible and disfiguring disorder characterized by involuntary
movements of the face, tongue, or extremities
FDA APPROVAL: 1979
28
30. Interactive Question
Which one of these agents have your patients been prescribed?
Metoclopramide(Reglan) for 90 days or less
Metoclopramide(Reglan) for greater then 90 days
Erythromycin for 90 days or less
Erythromycin for greater then 90 days
Domperidone * expanded access IND
I do not have any experience with these medications
30
31. Meta analysis: Effect of Medications on Symptom
Improvement and Gastric Emptying
31
Janssens P et al, Am
J Gastroenterol
2013;108:1382-91
33. Neuromodulators Improve Symptoms in
Functional Nausea and Vomiting
33
Patel A, et al, Postgrad Med J 2013;89:131-6
Agents used:
Tricyclic antidepressants-Pamelor etc
SSRI- Lexapro, Zoloft etc
SNRI- Cymbalta etc
Zonisamide- Zonegran
Levetiracetam- Keppra
34. Time trends in gastroparesis treatment
34
Shifted away from prokinetics > towards
symptomatic management with antiemetics, and
neuromodulators
Dudekula A, et al. Dig Dis Sci. 2014.
35. Gastric Electrical Stimulation-Medtronic
EnterraTM
May consider for:
Chronic vomiting
Symptomatic disorders with abnormal gastric
emptying
Failure of medical therapy
Non-narcotic based symptoms
Candidate for abdominal surgery
Evidence?
Does not necessarily improve gastric emptying
Not of value in cyclic vomiting
35
http://www.medtronic.com/us-en/patients/treatments-therapies/neurostimulator-
gastroparesis/enterra-2-neurostimulator.html
38. Management of Symptoms
38
Adopted from:
C. Prakash Gyawali, MD, MRCP
Professor of Medicine
Director, GI Fellowship Training
Program Director,
Neurogastroenterology and Motility
Program
39. Take Home Message
Gastric Emptying study gives you the best insight to validate
gastroparesis and rule out anything else
Nutrition and glycemic controls are the first line of defense
Liquid and Semi-Solid small meals empty better vs solid
meals
Prokinetics and Neuromodulators may help patients alleviate
symptoms but have varied results on gastric emptying
39
40. Questions?
Vishal Bagchi MBA, RD, LD
Director of Medical and
Scientific Affairs
Patient Care America
vbagchi@pcacorp.com
https://www.linkedin.com
/in/vishalb3/
40
41. Interactive Question
Rank These By Ease Of Patient Compliance:
1=Easiest to comply with 5= Hardest to comply with
• Small frequent (6/day) meals
• Reduced fat (<40 gm/day)
• Reduced fiber
• Liquid caloric supplementation
• Glycemic control
41
Park MI, Camilleri M. Gastroparesis: clinical update. Am J Gastroenterol. 2006;101:1129-1139.
11
Renagel [package insert]. Cambridge, Mass: Genzyme Corporation; 2004.
Diabetic Patients With Gastroparesis and Chronic Kidney Disease -- Management of Malnutrition: An Expert Interview With William F. Finn, MD
Authors:William Finn
Different area of the stomach do not do what they are suppose to
Approved GLP-1 agonists:
exenatide (Byetta/Bydureon), approved in 2005/2012
liraglutide (Victoza, Saxenda), approved 2010[6]
lixisenatide (Lyxumia), approved in 2016[7]
albiglutide (Tanzeum), approved in 2014 by GSK[8]
dulaglutide (Trulicity), approved in 2014—manufactured by Eli Lilly[9]
semaglutide (Ozempic), approved in 2017.[10]
Carol Rees Parrish MS, RD and Nutrition Support Specialist University of Virginia Health System Digestive Health Center of Excellence Charlottesville, VA President/Founder, GPDA 5520 Dalhart Hill NW Calgary, AB T3A 1S9
Legumes/Dried Beans (refried beans, baked beans, black-eyed peas, lentils, black, pinto, northern, fava, navy, kidney, garbanzo beans, soy beans)
Bran /Whole Grain Cereals (such as bran cereals, Grape-Nuts®, shredded wheat type, granolas)
Nuts and Seeds (pumpkin seeds, soy nuts, chunky nut butters)
Fruits (blackberries, blueberries, raspberries, strawberries, oranges, kiwi)
Dried fruits (apricots, dates, figs, prunes, raisins)
Vegetables (green peas, broccoli)
Foods Associated with Bezoar Formation
Popcorn, Apples, Berries, Brussels sprouts, Coconuts, Corn, Figs, Green beans, Legumes, Oranges, Persimmons, Potato peels, Sauerkraut, Tomato skins
High Fiber Medications/Bulking Agents
Acacia fiber; Benefiber®; Citrucel®; FiberChoice®; Fibercon®; Konsyl®; Metamucil®; Perdiem Fiber, or any psyllium product
Abstract
Background
Nutrition therapy for gastroparesis focuses on reducing meal size, fiber, fat intake, and increasing liquids intake relative to solid foods. Evidence to support these dietary interventions has been anecdotal. The aim of this study was to determine the effect of fat intake and solid/liquid meal consistency on symptoms in gastroparesis.
Methods
Twelve patients with gastroparesis were studied on four separate days receiving one of four meals each day in a randomized order: high-fat solid, high-fat liquid, low-fat liquid, and low-fat solid meal. At each visit, eight gastrointestinal symptoms were rated from 0 (none) to 4 (very severe) every 15 min, before and for 4 h after meal ingestion.
Key Results
There was an increase in the total symptom score in the following order: high-fat solid > low-fat solid > high-fat liquid > low-fat liquid. For the high-fat solid meal, symptoms remained elevated throughout the 4 h postprandial period. Severity of nausea more than doubled after the high-fat solid meal, whereas the low-fat liquid meal caused the least increase in nausea.
Conclusions & Inferences
A high-fat solid meal significantly increased overall symptoms among individuals with gastroparesis, whereas a low-fat liquid meal had the least effect. With respect to nausea, low-fat meals were better tolerated than high-fat meals, and liquid meals were better tolerated than solid meals. These data provide support for recommendations that low-fat and increased liquid content meals are best tolerated in patients with symptomatic gastroparesis.
Neurogastroenterol Motil. 2015 Apr;27(4):501-8. doi: 10.1111/nmo.12519. Epub 2015 Jan 19.
Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis.
Homko CJ1, Duffy F, Friedenberg FK, Boden G, Parkman HP.
Zelnorm – tegaserod not available
The MMC originates mostly in the stomach—although ~25% will arise from the duodenum or proximal jejunum—and can travel to the distal end of the ileum.[3] They consist of four distinct phases:
Boron, Walter F.; et, al, eds. (2012). Medical physiology : a cellular and molecular approach(Updated second ed.). Philadelphia, Pa.: Saunders. ISBN 978-1437717532.
Designed in 1970’s convert any phase of MMC to phase 3 MMC emptying undigested emptying into intestines. Reglan induces that even if you have just eaten- Causing mostly likely causing diarrhea. Small intestine is not ready. GI Bleed - IV Reglan
Keep giving it, effect goes away.
Works like a neuro modulators,
In the United States, domperidone is not currently a legally marketed human drug and it is not approved for sale in the U.S. On 7 June 2004, FDA issued a public warning that distributing any domperidone-containing products is illegal.[12]
It was reported in 2007 that domperidone is available in 58 countries, including Canada,[10] but the uses or indications of domperidone vary between nations. In Italy it is used in the treatment of gastroesophageal reflux disease and in Canada, the drug is indicated in upper gastrointestinal motility disorders and to prevent gastrointestinal symptoms associated with the use of dopamine agonist antiparkinsonian agents.[11] In the United Kingdom, domperidone is only indicated for the treatment of nausea and vomiting and the treatment duration is usually limited to 1 week.
Cisapride is only available in the United States to special patients who are signed up by their doctors. Talk to your doctor or pharmacist about whether you should be taking cisapride. Cisapride may cause serious irregular heart beats
On March 30, 2007, the FDA asked Novartis to suspend its U.S. marketing and sales because a safety analysis found a higher chance of heart attack, stroke, and unstable angina (heart/chest pain) in patients treated with Zelnorm compared with treatment with an inactive substance (placebo).
Prucalopride was approved for use in Europe in 2009,[8] in Canada in 2011[9] and in Israel in 2014[10] but it has not been approved by the Food and Drug Administration for use in the United States.
relationship between symptom improvement (SI) and acceleration of gastric emptying (GE)
metoclopramide (n=6), domperidone (n=6), cisapride (n=14), erythromycin (n=3), botulinum toxin (n=2), and levosulpiride (n=3).
The relation between symptom improvement and gastric emptying in the treatment of diabetic and idiopathic gastroparesis.
Janssen P1, Harris MS, Jones M, Masaoka T, Farré R, Törnblom H, Van Oudenhove L, Simrén M, Tack J.
The Food and Drug Administration (FDA) approved these cyclic antidepressants to treat depression:
Tricyclic antidepressants:
Amitriptyline
Amoxapine
Desipramine (Norpramin)
Doxepin
Imipramine (Tofranil)
Nortriptyline (Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
The Food and Drug Administration (FDA) has approved these SSRIs to treat depression:
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil, Pexeva)
Sertraline (Zoloft)
Vilazodone (Viibryd)
The Food and Drug Administration (FDA) has approved these SNRIs to treat depression:
Desvenlafaxine (Pristiq, Khedezla)
Duloxetine (Cymbalta) ― also approved to treat anxiety and certain types of chronic pain
Levomilnacipran (Fetzima)
Venlafaxine (Effexor XR) ― also approved to treat anxiety and panic disorder
Ondansetron –Zofran
Dudekula A, et al. Dig Dis Sci. 2014.
Show full citation
Abstract
INTRODUCTION: While delayed emptying is the defining criterion for gastroparesis, prokinetics often only have a limited impact on symptoms and have been associated with potentially serious adverse effects. The goal of this study was to determine how this information and regulatory changes affected gastroparesis management.
METHODS: The electronic medical records of patients seen between 2003 and 2012 in the outpatient clinic of a large tertiary center were retrieved based on the billing diagnosis of gastroparesis. Demographic, clinical, and survival data were abstracted.
RESULTS: A total of 709 patients were identified, with diabetes (21.2 %) and prior surgery (9.8 %) being the most common identifiable causes. The majority of patients (56 %) had idiopathic gastroparesis. The cohort was female predominant (79.5 %) with an average age of 45.4 ± 0.6 years. At the index encounter, 61.8 % received prokinetics. About one-third (37.7 %) used antiemetics at least intermittently. Between 2003 and 2012, prokinetic use dropped from 81 to 43 %, while the use of antiemetics increased from 14 to 41 %. Similarly, there was a significant increase in prescribed opioids and antidepressants. During the period of the study, 44 patients (6.2 %) died. Increasing age, a higher comorbidity burden, anxiety, and medication use were associated with higher mortality risks.
CONCLUSION: This large outpatient cohort suggests that treatment trends move away from prokinetics and focus on symptom-oriented therapy and/or confounding mood disorders.
Weekly vomiting frequency (median and interquartile range). The bar graph illustrates the changes in weekly vomiting frequency as recorded in patient diaries at baseline, during the ON and OFF periods of the double-blind phase, and at 6 and 12 months during the open-label phase. Diabetic: baseline, n = 17; ON, n = 17; OFF, n = 17; 6 months, n = 13; 12 months, n = 11. Idiopathic: baseline, n = 16; ON, n = 16; OFF, n = 16; 6 months, n = 14; 12 months, n =13. (†P < 0.05, ON vs. OFF; ∗P < 0.05 vs. baseline; ∗∗P< 0.05 vs. OFF).
Gastric electrical stimulation for medically refractory gastroparesis☆
Thomas Abell
, Richard McCallumCorrespondence information about the author Richard McCallumEmail the author Richard McCallum
, Michael Hocking
, Kenneth Koch
, Hasse Abrahamsson
, Isabelle LeBlanc
, Greger Lindberg
, Jan Konturek
, Thomas Nowak
, Eammon M.M Quigley
, Gervais Tougas
, Warren Starkebaum
Methods:
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.
Results:
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.
Conclusions:
High-frequency/low-energy gastric electrical stimulation significantly decreased vomiting frequency and gastrointestinal symptoms and improved quality of life in patients with severe gastroparesis.
Summary
Gastroparesis and functional dyspepsia can be indistinguishable by clinical presentation
Delayed gastric emptying is the basis of diagnosis of gastroparesis, but can be also be encountered in functional dyspepsia
Interest has shifted towards symptom based management approaches over prokinetic therapy
Neuromodulators and gastric electrical stimulation are options in refractory states
Identified Gap(s): Limited knowledge of gastroparesis etiology and treatment options by Dietitians and other practitioners.
Description of current state: ESRD patients are commonly affected by gastroparesis and practitioners often have a limited understanding of
scientifically proven therapies to improve patient outcomes, reduce hospitalizations, and improve quality of life.
Description of desired/achievable state: Increased knowledge of scientifically based interventions for gastroparesis
Gap to be addressed by this activity: Dietitians’ lack of comfort in making sound recommendations for patients with gastroparesis
Activity Overview: The purpose of this activity is to enable the learner to identify the common causes of gastroparesis in CKD, differentiate
gastroparesis vs other GI issues and their symptoms, and compare and contrast various evidence-based treatments for gastroparesis, and recognize three take-home strategies to offer patients/physicians..
130 patients with idiopathic gastroparesis from 7 centersAbnormal gastric emptying study, and GCSI score >21 required for enrollment Equally randomized to nortriptyline and placebo
Gastroparesis Cardinal Symptom Index (GCSI): development and validation of a patient reported assessment of severity of gastroparesis symptoms.
Gastroparesis Cardinal Symptom Index (GCSI): development and validation of a patient reported assessment of severity of gastroparesis symptoms.
Revicki DA1, Rentz AM, Dubois D, Kahrilas P, Stanghellini V, Talley NJ, Tack J.
Author information
Abstract
BACKGROUND:
Patient-rated symptom assessments are needed for evaluating the effectiveness of medical treatments and for monitoring outcomes in gastroparesis.
OBJECTIVE:
This paper summarizes the development and psychometric evaluation of a new instrument, the Gastroparesis Cardinal Symptom Index (GCSI), for assessing severity of symptoms associated with gastroparesis.
METHODS:
The GCSI was based on reviews of the medical literature, patient focus groups, and interviews with clinicians. A sample of 169 patients with a documented diagnosis of gastroparesis participated in the psychometric evaluation study. Patients completed the GCSI, the SF-36 Health Survey, and disability days questions at baseline and after 8 weeks. A randomly selected sub-sample of 30 subjects returned at 2 weeks to assess test retest reliability. Clinicians rated severity of symptoms, and both clinicians and patients rated change in gastroparesis-related symptoms over the 8 week study.
RESULTS:
The GCSI is based on three subscales: post-prandial fullness/early satiety (4 items); nausea/vomiting (3 items), and bloating (2 items). Internal consistency reliability was 0.84 for the GCSI total score and ranged from 0.83 to 0.85 for the subscale scores. Two week test retest reliability was 0.76 for the total score and ranged from 0.68 to 0.81 for subscale scores. Construct validity was supported, given that we observed significant relationships between clinician assessed symptom severity and GCSI total score, significant differences between gastroparesis and dyspepsia patients (n = 760) on GCSI total (p < 0.0001) and subscale scores (p < 0.03 to p < 0.0001), moderate and significant relationships between GCSI total and SF-36 scores, and significant associations between GCSI total score and reports of restricted activity and bed disability days. Patients with greater symptom severity, as rated by clinicians, reported more symptom severity on GCSI total score. GSCI total scores were responsive to changes in overall gastroparesis symptoms as assessed by clinicians (p < 0.0001) and patients (p = 0.0004).