Ultrasonographic assessment of preoperative gastric volume in patients with dyspepsia: a prospective observational study

Background Patients undergoing gastroenteroscopy during sedation are prone to aspiration, and most patients with dyspepsia have delayed gastric emptying. This study aimed to investigate the feasibility of measuring the gastric antrum cross-sectional area (CSA) to supply a novel clinical diagnostic reference value in patients with dyspepsia. Methods Patients with dyspepsia undergoing elective gastroscopy were included. The Perlas qualitative 0–2 grading scale score was determined before the operation. The anteroposterior diameter (D1) and craniocaudal diameter (D2) between gastric antrum serosal surfaces were measured perpendicular to each other in the supine and right lateral decubitus (RLD) positions. CSA values in the supine position and RLD position were determined. Gastric contents were endoscopically suctioned with the volumes measured and noted as actual gastric volume. Multiple regression analysis was used to fit a mathematical model for estimating the gastric volume. Receiver operating characteristic (ROC) curves were constructed to determine the accuracy of RLD CSA to detect gastric volumes of > 0.8 ml/kg. Results A total of 117 patients were enrolled and divided into a functional dyspepsia (FD) group and an organic dyspepsia group according to gastroscopy findings. For a gastric volume of > 0.8 ml/kg, cut-off values for FD and organic dyspepsia were 6.7 cm2 and 10.0 cm2, respectively. Two new modified mathematical models were derived to predict an estimated gastric volume for FD and organic dyspepsia: volume = 3.93 × RLD CSA - 0.47 × age; and volume = 6.15 × RLD CSA - 0.61 × age. Conclusion We used the cut-off value of the antral area for the fast diagnosis of gastric volumes in patients with dyspepsia, which may assist clinicians in identifying patients at risk of aspiration. Trial registration www.chictr.org.cn (CHICTR-DDD-17010871); registered 15 March 2017.

Efficacy of Nasogastric and Nasojejunal Enteral Feeding in the Early Phase of Acute Pacreatitis

Enteral nutrition in the early phase of predicted severe acute pancreatitis can be administered via a nasogastric or nasojejunal tube. Finding the most effective method in terms of daily balance, the volume of feeding and residual gastric volume in the early period of moderate and severe acute pancreatitis is a current challenge.The aim of the study was to estimate the efficacy of nasogastric and nasojejunal early enteral feeding duringthe early phase of predicted severe acute pancreatitis.Material and methods. The study was prospective, single-center, and randomized. The data were collected from November 2012 to October 2018. The study included 64 ICU patients in the early period of acute pancreatitis exhibiting predictors of severity. During randomization, the patients were assigned to either nasogastric (group 1) or nasojejunal (group 2) feeding for the next four days. The volume of enteral feeding on Day 1 was 250 ml/day, and on each successive day it was increased by 250 ml/day. During group allocation, the disease severity and the way of nutrient administration were taken into account. Daily balance was calculated using the difference between enterally administered and residual gastric volume. Statistical analysis was performed using SPSS v.23 software package. The null hypothesis was rejected at P0.05.Results. The volume of enteral nutrition administered over 4 days did not differ between the study groups. Patients with severe acute pancreatitis had significantly better nutrient absorption over 4 days when the postpyloric route was used (1.63±0.98 l/d) vs the nasogastric one (0.55±0.29 l/d) (P=0.001). In moderate pancreatitis, the enteral nutrition absorption over 4 days did not differ (P=0.107) between the groups with nasogastric (2.06±0.87 l/day) and nasojejunal (2.6±0.45 l/day) feeding.Conclusion. Nasojejunal route is the preferred way to start enteral feeding in patients with severe acute pancreatitis. In moderate acute pancreatitis, feeding can be initiated via the gastric route and only in case of intolerance it should be switched to the nasojejunal one.

Managing the Unpredictable: Mechanistic Analysis and Clinical Recommendations for Lamotrigine Treatment after Bariatric Surgery

Bariatric surgery may alter the absorption and overall bioavailability of oral drugs. Lamotrigine is a major antiepileptic and mood stabilizer, that its use after bariatric surgery has not yet been studied. In this article, we provide a thorough mechanistic analysis of the effects of bariatric surgery on multiple mechanisms important for the absorption, bioavailability and overall pharmacokinetics of lamotrigine. Attributable to its pharmacokinetic properties and drug characteristics, the use of lamotrigine after bariatric surgery may be challenging. The complex situation in which some mechanisms may lead to increased drug exposure (e.g., decreased metabolism, weight loss) while others to its decrease (e.g., hampered dissolution/solubility, decreased gastric volume), may result in lowered, unchanged, or enhanced lamotrigine plasma levels after the surgery. We conclude with a set of clinical recommendations for lamotrigine treatment after bariatric surgery, aiming to allow better patient care, and emphasizing the extra caution that needs to be taken with these patients.

Endoscopic Treatment of Obesity and Nutritional Aspects of Bariatric Endoscopy

Obesity is a significant problem worldwide. Several serious diseases that decrease patient quality of life and increase mortality (high blood pressure, dyslipidaemia, type 2 diabetes etc.) are associated with obesity. Obesity treatment is a multidisciplinary and complex process that requires maximum patient compliance. Change of lifestyle is fundamental in the treatment of obesity. While pharmacotherapeutic options are available, their efficacy is limited. Surgical treatment though highly effective, carries the risk of complications and is thus indicated mostly in advanced stages of obesity. Endoscopic treatments of obesity are less invasive than surgical options, and are associated with fewer complications and nutritional deficits. Currently, there is a large spectrum of endoscopic methods based on the principles of gastric volume reduction, size restriction and gastric or small bowel bypass being explored with only few available in routine practice. The aim of this publication is to present an up-to-date summary of available endoscopic methods for the treatment of obesity focusing on their efficacy, safety and nutritional aspects.

Radiographic Measurement of Gastric Remnant Volume After Laparoscopic Sleeve Gastrectomy: Assessment of Reproducibility and Correlation with Weight Loss

Background As a restrictive procedure, laparoscopic sleeve gastrectomy (LSG) relies primarily on the reduction of gastric volume. It has been suggested that an immediate postoperative gastric remnant volume (GRV) may influence long-term results of LSG; however, there are no consensus in this matter. The aim of this study was to assess the reproducibility of different radiographic methods of GRV calculation and evaluate their correlation with the weight loss (WL) after surgery. Methods This retrospective study evaluated 174 patients who underwent LSG in the period from 2014 to 2017. Using UGI, GRV was measured with 3 different mathematical methods by 2 radiologists. Intraobserver and interobserver calculations were made. Correlation between GRV and WL were estimated with calculations percentage of total weight loss (%TWL) and percentage of excess weight loss (%EWL) after 1, 3, 6, 12, 18, and 24 months postoperatively. Results During analysis of intraobserver similarities, the results of ICC calculation showed that reproducibility was good to excellent for all GRV calculation methods. The intraobserver reproducibility for Reader I was highest for cylinder and truncated cone formula and for Reader II for ellipsoid formula. The interobserver reproducibility was highest for ellipsoid formula. Regarding correlation between GRV and WL, significant negative correlation has been shown on the 12th month after LSG in %TWL and %EWL for every method of GRV calculation, most important for ellipsoid formula (%TWL – r(X,Y) = -0.335, p < 0.001 and %EWL – r(X,Y) = -0.373, p < 0.001). Conclusion Radiographic methods of GRV calculation are characterized by good reproducibility and correlate with the postoperative WL. Graphical Abstract

Effect of Trianthema triquetra Rottl. ex Willed (Aizoaceae) on ethanol-induced gastric ulcers in experimental rats

Trianthema triquetra Rottl. Ex.Willed (T. triquetra) is a medicinal plant that belongs to the family Aizoaceae. The plant has been used traditionally as fodder, as a remedy for chronic ulcer, fever, and healing wounds. Therefore, the present study was intended to investigate the anti-ulcer ability of different fractions of T. triquetra to verify its folklore use in ulcer cure. Acute oral toxicity of all the fractions of T. triquetra was evaluated at a dose of 2g/kg b.wt. Anti-ulcer potential of nbutanol (TTB), chloroform (TTC), ethyl acetate (TTEA) and aqueous (TTA) fraction of crude methanolic extract of T. triquetra was assessed by using ethanol- induced gastric ulcer model in rats. Omeprazole at a dose of 20 mg/kg b.wt. was used as standard drug. After 1 hour of administration of all the fractions of T. triquetra, at a dosage of 300mg/kg b.wt., the gastric ulcer was induced in all animals by administering absolute ethanol (1mL/animal) orally except normal control group. After an hour, all the rats were sacrificed. Ulcer index, % age of ulcer inhibition, gastric pH, gastric volume, total acidity, gastric wall protein, gastric wall mucus and histopathology of the stomach wall of rats were assessed. All fractions of T. triquetra showed a substantial decrease in ulcer index and improvement in percentage inhibition compared to the disease control group. There was a rise in the amount of gastric wall mucus content, total protein content, gastric pH and a decrease in gastric volume and total acidity. Histopathological studies showed severe mucosal injury, leucocyte infiltration and edema in the disease control group compared to omeprazole and plant fractions treated animal groups. The present work encourages the conventional use of T. triquetra in the cure of ulcers.

Efficacy and Mechanisms of Gastric Volume-Restriction Bariatric Devices

Obesity is a chronic disease that affects over 795 million people worldwide. Bariatric surgery is an effective therapy to combat the epidemic of clinically severe obesity, but it is only performed in a very small proportion of patients because of the limited surgical indications, the irreversibility of the procedure, and the potential postoperative complications. As an alternative to bariatric surgery, numerous medical devices have been developed for the treatment of morbid obesity and obesity-related disorders. Most devices target restriction of the stomach, but the mechanism of action is likely more than just mechanical restriction. The objective of this review is to integrate the underlying mechanisms of gastric restrictive bariatric devices in obesity and comorbidities. We call attention to the need for future studies on potential mechanisms to shed light on how current gastric volume-restriction bariatric devices function and how future devices and treatments can be further improved to combat the epidemic of obesity.

COMPARATIVE STUDY OF METOCLOPRAMIDE AND ONDANSETRON WITH PANTOPRAZOLE IN ELECTIVE CAESEREAN SECTION UNDER SPINAL ANAESTHESIA FOR ASPIRATION PNEUMONITIS PROPHYLAXIS.

BACKGROUND- Caesarean delivery, one of the most commonly performed surgical procedure. The choice of anaesthesia is spinal blockade for elective caeserean-section,unless general anaesthesia is specically indicated. Aspiration pneumonitis remains an important cause of morbidity and mortality in anaesthesia practise,particularly in obstetric patients,prophylaxis against it is paramount importance in pre-anaesthetic management. AIMS AND OBJECTIVES- The aim of this study was to compare pH and volume of gastric contents after administration of combination of metoclopramide and pantoprazole versus ondansetron and pantoprazole during elective caesarean section under spinal anaesthesia for prophylaxis against aspiration pneumonitis. METHODS: It is a prospective study where 100 parturient women, ASA 1 and 2 scheduled for elective caesarean section. They were divided into 2 groups: ondansetron(4mg) and pantoprazole(40mg),and metoclopramide(10mg), pantoprazole(40mg) administered intravenously 2hours before surgery. Gastric aspirate was taken in various positions before giving spinal anaesthesia and at the end of operation. Patients at risk were according to criteria of gastric volume more than 0.4ml/kg with pH <2.5. RESULTS:Patients at risk were 7(14%) in metoclopramide group and 1(2%) in ondansetron group before giving spinal anaesthesia(p=0.027) and 6(12%) in metoclopramide group and 0(0%) in ondansetron group at end of operation(p=0.012) . Since p-value was less than 0.05 there was signicant difference between two groups. CONCLUSION: As there was signicant difference between ondansetron and metoclopramide , it is recommended to use ondansetron and pantoprazole for prophylaxis against aspiration pneumonitis.

Phytochemical and Pharmacological Evaluation of Annona reticulate

Annona reticulate (AR) is indigenous to the tropical areas of India and worldwide. The use of plant as remedy for diarrhea and ulcer is well documented in Ayurvedic system of medicine. However, pharmacological evidence does not exist to substantiate its therapeutic efficacy for the same. The aim was to investigate the antiulcer and anti-diarrheal activity of methanolic (ME) and aqueous extracts (AE) of A. reticulate in animal model. The antiulcer activity of extracts was investigated using ethanol and pylorus ligation-induced ulcer. The anti-diarrheal activity of MEAR and AEAR extracts was evaluated by castor oil induced diarrhea and gastro intestinal motility using parameters such as onset of diarrhea, number of wet stools, total number of stool and weight of total number of stools. The antiulcer activity of the extracts was confirmed by a reduction in ulcer index along with the decrease in gastric volume, total acidity, and an increase in pH of gastric content in both the models. A. reticulate extracts were more efficacious in reducing number of total stools in both the models of diarrhea and showed a dose-dependent antidiarrheal effect. The obtained results have established a pharmacological evidence for the folkloric use of the A. reticulate as antiulcer and antidiarrhoeal agent.