Severe Botulism after Intragastric Botulinum Toxin-A Injection: A Case Series

Intragastric botulismus toxin-A (BoNT-A) is one of the new approaches in the treatment of obesity. We aimed to contribute to the literature by presenting the clinical features, laboratory findings and treatment responses of iatrogenic botulism cases due to intragastric BoNT-A administered in our clinic. All detailed medical information was obtained by accessing the medical records of the patients who were hospitalized and followed up and treated between September 2022 and December 2022, and the diagnosis of A.05.1 Botulism was entered according to ICD-10, and whose clinical findings were compatible with botulism disease and who underwent intragastric BoNT-A application beforehand. These records were obtained by examining this information. 10 patients who developed botulism after intragastric BoNT-A application between 01/09/2022 and 28/02/2023 were followed up in our clinic. All of the patients were women. The mean age was 35. The mean hospital stay was 9 days. Only 1 of our cases required intensive care. Good response to treatment was accepted as a complete or near-complete improvement in the clinical findings of the patients and all of them had a good response to treatment. Intragastric BoNT-A administration is a procedure that requires careful indication with a profit/loss calculation considering the potential side effects. In addition, attention should be paid to dilution rates and dose amounts.

Promising way to address massive intragastric clotting in patients with acute upper gastrointestinal bleeding:A case report

BACKGROUND Massive intragastric clotting(MIC) makes endoscopic therapy difficult in patients with acute upper gastrointestinal bleeding. Literature data on how to address this problem are limited. Here, we report on a case of massive stomach bleeding with MIC that was successfully treated endoscopically using an overtube of singleballoon enteroscopy.CASE SUMMARY A 62-year-old gentleman with metastatic lung cancer was admitted to the intensive care unit due to tarry stools and hematemesis of 1500 mL of blood during hospitalization. Emergent esophagogastroduodenoscopy revealed massive blood clots and fresh blood in the stomach with evidence of active bleeding.Bleeding sites could not be observed even by changing the patient’s position and aggressive endoscope suction. The MIC was successfully removed using an overtube connected with a suction pipe, which was inserted into the stomach with an overtube of a single-balloon enteroscope. An ultrathin gastroscope was also introduced through the nose into the stomach to guide the suction. A massive blood clot was successfully removed, and an ulcer with oozing bleeding at the inferior lesser curvature of the upper gastric body was revealed, facilitating endoscopic hemostatic therapy.CONCLUSION This technique appears to be a previously unreported method to suction MIC out of the stomach in patients with acute upper gastrointestinal bleeding. This technique could be considered when other methods are not available or if they fail to remove massive blood clots in the stomach.

Comparative evaluation of intragastric bile acids and hepatobiliary scintigraphy in the diagnosis of duodenogastric reflux

AIM:To assess the diagnostic value of a combination of intragastric bile acids and hepatobiliary scintigraphy in the detection of duodenogastric reflux(DGR).METHODS:The study contained 99 patients with DGR and 70 healthy volunteers who made up the control group.The diagnosis was based on the combination of several objective arguments:a long history of gastric symptoms(i.e.,nausea,epigastric pain,and/or bilious vomiting) poorly responsive to medical treatment,gastroesophageal reflux symptoms unresponsive to protonpump inhibitors,gastritis on upper gastrointestinal(GI) endoscopy and/or at histology,presence of a bilious gastric lake at > 1 upper GI endoscopy,pathologic 24-h intragastric bile monitoring with the Bilitec device.Gas-tric juice was aspirated in the GI endoscopy and total bile acid(TBA),total bilirubin(TBIL) and direct bilirubin(DBIL) were tested in the clinical laboratory.Continuous data of gastric juice were compared between each group using the independent-samples Mann-Whitney U-test and their relationship was analysed by Spearman's rank correlation test and Fisher's linear discriminant analysis.Histopathology of DGR patients and 23 patients with chronic atrophic gastritis was compared by clinical pathologists.Using the Independent-samples Mann-Whitney U-test,DGR index(DGRi) was calculated in 28 patients of DGR group and 19 persons of control group who were subjected to hepatobiliary scintigraphy.Receiver operating characteristic curve was made to determine the sensitivity and specificity of these two methods in the diagnosis of DGR.RESULTS:The group of patients with DGR showed a statistically higher prevalence of epigastric pain in comparison with control group.There was no significant difference between the histology of gastric mucosa with atrophic gastritis and duodenogastric reflux.The bile acid levels of DGR patients were significantly higher than the control values(Z:TBA:-8.916,DBIL:-3.914,TBIL:-6.197,all P < 0.001).Two of three in the DGR group have a significantly associated with each other(r:TBA/DBIL:0.362,TBA/TBIL:0.470,DBIL/TBIL:0.737,all P < 0.001).The Fisher's discriminant function is followed:Con:Y = 0.002TBA + 0.048DBIL + 0.032TBIL 0.986;Reflux:Y = 0.012TBA + 0.076DBIL + 0.089TBIL-2.614.Eighty-four point zero five percent of original grouped cases were correctly classified by this method.With respect to the DGR group,DGRi were higher than those in the control group with statistically significant differences(Z =-5.224,P < 0.001).Twenty eight patients(59.6%) were deemed to be duodenogastric reflux positive by endoscopy,as compared to 37 patients(78.7%) by hepatobiliary scintigraphy.CONCLUSION:The integrated use of intragastric bile acid examination and scintigraphy can greatly improve the sensitivity and specificity of the diagnosis of DGR.

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, spaceoccupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo Over Stitch, Trans Oral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoB arrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons(Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and Sati Sphere. The Aspire Assist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo Over Stitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.

Intragastric surgery using laparoscopy and oral endoscopy for gastric submucosal tumors

We review the techniques and outcomes of the intragastric resection for gastric submucosal tumors(GSTs) using laparoscope and oral endoscope. In the literature, the mean operation time, intraoperative blood loss, pathological size of the tumor and postoperative hospital stay were 134 min, minimal, 31 mm and 6.4 d, respectively. There were no particular perioperative complications during the follow-up period(mean: 121.3 mo). Intragastric surgery using laparoscopy and oral endoscopy can be considerably beneficial for patients with GSTs locating in the upper third of the stomach between 2-5 cm in diameter and < 8 cm2 in crosssectional area and located in the upper third of the stomach.

Six intragastric balloons:Which to choose?

Endoscopically placed intragastric balloons(IGBs)have played a significant role in obesity treatment over the last 30 years,successfully bridging the gap between lifestyle modification/pharmacotherapy and bariatric surgery.Since they provide a continuous sensation of satiety that helps the ingestion of smaller portions of food,facilitating maintenance of a low-calorie diet,they have generally been considered an effective and reversible,less invasive,non-surgical procedure for weight loss.However,some studies indicate that balloons have limited sustainable effectiveness for the vast majority attempting such therapy,resulting in a return to the previous weight after balloon removal.In this review we try to summarize the pros and cons of various balloon types,to guide decision making for both the physician and the obese individual looking for effective treatment.We analyzed the six most commonly used IGBs,namely the liquid-filled balloons Orbera,Spatz3,ReShape Duo and Elipse,and the gas-filled Heliosphere and Obalon-also including comments on the adjustable Spatz3,and the swallowable Obalon and Elipse-to optimize the choice for maximum efficacy and safety.

Current status of intragastric balloon for obesity treatment

Endoscopic bariatric therapy may be a useful alternative to pharmacological treatment for obesity, and it provides greater efficacy with lower risks than do conventional surgical procedures. Among the various endoscopic treatments for obesity, the intragastric balloon is associated with significant efficacy in body weight reduction and relief of comorbid disease symptoms. Anatomically, this treatment is based on gastric space-occupying effects that increase the feeling of satiety and may also affect gut neuroendocrine signaling. The simplicity of the intragastric balloon procedure may account for its widespread role in obesity treatment and its applicability to various degrees of obesity. However, advances in device properties and procedural techniques are still needed in order to improve its safety and cost-effectiveness. Furthermore, verification of the physiological outcomes of intragastric balloon treatment and the clinical predictive factors for treatment responses should be considered. In this article, we discuss the types, efficacy, safety, and future directions of intragastric balloon treatment.

Efficacy of intragastric balloon on weight reduction:Saudi perspective

AIM To evaluate the safety and efficacy of intragastric balloon(IGB) in weight reduction in obese patients referred to a tertiary hospital in the Kingdom of Saudi Arabia.METHODS Three hundred and one consecutive obese individuals, who underwent IGB placement during January 2009 to May 2015, were analyzed. The subjects aged 18 to 60 years and had a minimum body mass index(BMI) of 27 kg/m^2. The IGB was placed under conscious sedation and kept for 6 mo. Anthropometric measurements were recorded during and after 6 mo of IGB removal.RESULTS The body weight, excess body weight, and BMI were significantly reduced at the time of IGB removal and 6 mo later. Body weight loss > 10% was achieved in 224 subjects at removal of IGB. End of treatment success and long-term success were both significantly observed in women(70 vs 11)(71 vs 12.5) respectively. Excess BMI loss was significantly higher in subjects retaining the IGB for over 6 mo both at the removal [43.44 ± 19.46(n = 221) vs 55.60 ± 28.69(n = 80); t = 4.19, P = 0.0001] as well as at the end of 6 mo' follow-up [46.57 ± 24.89(n = 221) vs 63.52 ± 31.08(n = 80); t = 4.87, P = 0.0001]. Within 3 d of IGB placement, two subjects developed pancreatitis and one subject developed cardiac arrhythmia. Intestinal obstruction due to displacement of IGB occurred in two subjects. Allthese subjects recovered uneventfully after immediate removal of the IGB. CONCLUSION IGB was effective in our cohorts. The observed weight reduction was maintained for at least 6 mo post IGB removal. IGB placement was safe with a satisfactory tolerance rate.

Effects of intragastric balloon placement in metabolic dysfunctionassociated fatty liver disease: A systematic review and metaanalysis

BACKGROUND Metabolic dysfunction-associated fatty liver disease corresponds to a clinical entity that affects liver function triggered by the accumulation of fat in the liver and is linked with metabolic dysregulation.AIM To evaluate the effects of the intragastric balloon(IGB)in patients with metabolic dysfunction-associated fatty liver disease through the assessment of liver enzymes,imaging and several metabolic markers.METHODS A comprehensive search was done of multiple electronic databases(MEDLINE,EMBASE,LILACS,Cochrane and Google Scholar)and grey literature from their inception until February 2021.Inclusion criteria involved patients with a body mass index>25 kg/m2 with evidence or previous diagnosis of hepatic steatosis.Outcomes analyzed before and after 6 mo of IGB removal were alanine aminotransferase(IU/L),gamma-glutamyltransferase(IU/L),glycated hemoglobin(%),triglycerides(mg/dL),systolic blood pressure(mmHg),homeostatic model assessment,abdominal circumference(cm),body mass index(kg/m2)and liver volume(cm3).RESULTS Ten retrospective cohort studies evaluating a total of 508 patients were included.After 6 mo of IGB placement,this significantly reduced alanine aminotransferase[mean difference(MD):10.2,95%confidence interval(CI):8.12-12.3],gammaglutamyltransferase(MD:9.41,95%CI:6.94-11.88),glycated hemoglobin(MD:0.17%,95%CI:0.03-0.31),triglycerides(MD:38.58,95%CI:26.65-50.51),systolic pressure(MD:7.27,95%CI:4.79-9.76),homeostatic model assessment(MD:2.23%,95%CI:1.41-3.04),abdominal circumference(MD:12.12,95%CI:9.82-14.41)and body mass index(MD:5.07,95%CI:4.21-5.94).CONCLUSION IGB placement showed significant efficacy in improving alanine aminotransferase and gamma-glutamyltransferase levels in patients with metabolic dysfunctionassociated fatty liver disease as well as improving metabolic markers related to disease progression.

Impact of intragastric balloon on blood pressure reduction:A retrospective study in Eastern North Carolina

BACKGROUND Obesity has evolved into a global pandemic.The prevalence of obesity and hypertension in eastern North Carolina are comparable,if not higher,than the national prevalence.In the United States,an estimated 34%of adults have hypertension,the most modifiable risk factor for heart disease and stroke.Lifestyle and pharmacological interventions often do not provide sustained weight loss in obese patients.Bariatric surgery offers an effective weight reduction with short-and long-term health improvements;however,a higher body mass index is associated with higher surgical morbidity and mortality,longer hospitalization,and increasing rates of 30-day readmission due to comorbidities.Intragastric balloon may bridge a critical gap in the treatment of obesity.The objective of this paper is to showcase the impact of endoscopic bariatric therapy on blood pressure reduction.AIM To investigate the impact of intragastric balloon on blood pressure reduction.METHODS A retrospective chart review was conducted from January 1,2016 to January 31,2019 of consecutive adults who received intragastric balloon therapy(IGBT)in a gastroenterology private practice in Eastern North Carolina.The balloon was introduced into the stomach under endoscopic guidance,and while in the region of the gastric body,inflation with saline was performed at increments of 50 mL until target volume between 500 to 650 mL of saline was attained depending on the patient's gastric capacity.No procedural complications were noted during endoscopic placement and removal of the balloon.A cohort study design was used for data analysis.A total of 172 patients had the Orbera^(■)intragastric balloon placed.Of the 172 patients who had IGBT at baseline,11 patients(6.4%)requested early balloon removal due to foreign body sensation(n=1),and/or intolerable gastrointestinal adverse events(n=10).The reported gastrointestinal adverse events were nausea,vomiting,abdominal pain,and diarrhea.Eventually,6-mo follow-up data were available for only 140 patients.As a result,only the 140 available at the 6-mo follow-up were included in the analysis.Univariate,bivariate,and multivariate statistical analyses were performed.Specifically,scatterplots were created to show the relationship between weight and blood pressure,and paired two-sample t-test was carried out to determine if there was a significant reduction in weight before and after the IGBT.Multiple regressions were also performed to examine the association between participants’total body weight and blood pressure.The outcome variables for the multiple regression were systolic and diastolic blood pressure measured as continuous variables.This was followed by logistic regression analyses to determine the association between total body weight and hypertension at 6-mo post-implantation.The outcome variables for the logistic regression were systolic blood pressure–nonhypertensive(140 mmHg or less)or hypertensive(greater than 140 mmHg),and diastolic blood pressure–non-hypertensive(90 mmHg or less)or hypertensive(greater than 90 mmHg).All authors had access to the study data and reviewed and approved the final manuscript.All statistical analyses were done using STATA 14®.RESULTS The study included 15%males and 85%females.50%of the patients were white and just over 22%were non-white,and about 27%declined to give their race.The average baseline patients’weight prior to IGBT was 231.61 Lbs.(SD=46.53 Lbs.).However,the average patients’weight after IGBT at the 6-mo follow-up was 203.88 Lbs.(SD=41.04 Lbs.).Hence,on average,the percent total body weight loss at 6-mo is 11.97 after IGBT.The logistic regression performed revealed that weight(β=0.0140,P<0.000)and age(β=0.0534,P<0.000)are important factors in determining systolic blood pressure after IGBT.None of the other demographic characteristics or indicated comorbidities were found to be significant.CONCLUSION IGBT can be an effective short-term weight reduction modality with a relatively little risk of adverse event.Due to its improvement on systolic blood pressure,IGBT may help reduce cardiovascular risk.

Guinea Pig Model of Uterine Leiomyoma Established by Intragastric Administration of Estrogen

[Objective] The paper was to establish the guinea pig model of uterine leiomyoma by intragastric administration of estrogen and to discuss the effect of different doses and administration cycles on formation of uterine leiomyoma. [Method] Mature female guinea pigs were divided into short term model group and long term model group, and intragastrically administrated with estradiol valerate at the dose of 0.1 mg/100 g body weight twice a week for 6 and 8 weeks respectively. Guinea pigs intragastrically administrated with equal volume of normal saline were set as con- trol. After 6 or 8 weeks, the guinea pigs were sacrificed. The serum levels of estrogen and progesterone were measured by ELISA and the leiomyoma formation rate was measured. Histological changes were compared between treatment group and control group with HE staining. [Results] The leiomyoma formation rate was 30% in short term model group and 40% in long term model group. The overall leiomyoma formation rate was 35%. The serum level of estrogen in model animals increased significantly and the progesterone level decreased in long term model group. Histopathological examination confirmed that the guinea pig model of uterine leiomyoma was established successfully. [Conclusions] Intragastric administration of estrogen is a simple and effective method for establishing guinea pigs model of uterine leiomyoma.

How to establish an endoscopic bariatric practice

Obesity is a chronic,progressive,and relapsing disease of excess adiposity that contributes to more than two hundred medical conditions and is projected to affect more than half the adult population of the United States by the year 2030.Given the limited penetrance of traditional bariatric surgery,as well as the cost and adherence barriers to anti-obesity medications,there is growing interest in the rapidly evolving field of endoscopic bariatric therapies(EBTs).EBTs are minimally invasive,same-day,per-oral endoscopic procedures and include endoscopic sleeve gastroplasty,intragastric balloons,and endoscopic bariatric revisional procedures.This field represents an exciting and innovative subspe-cialty within gastroenterology.However,building a successful endoscopic bariatric practice requires intentional,coordinated,and sustained efforts to overcome the numerous obstacles to entry.Common barriers include acquisition of the technical and cognitive skillset,practice limitations including the availability of nutrition counseling,facility capabilities,direct-to-consumer marketing,and financial pressures such as facility and anesthesia fees.As the highest-volume center for metabolic and bariatric endoscopy in the United States,we provide insights into successfully establishing an endoscopic bariatric program.

Efficacy of Intragastric Balloons in the Markers of Metabolic Dysfunction-associated Fatty Liver Disease:Results from Meta-analyses

Background and Aims:Nonalcoholic fatty liver disease,now renamed metabolic dysfunction-associated fatty liver disease(MAFLD),is common in obese patients.Intragastric balloon(IGB),an obesity management tool with low complication risk,might be used in MAFLD treatment but there is still unexplained heterogeneity in results across studies.Methods:We conducted a systematic search of 152 citations published up to September 2020.Meta-analyses,stratified analyses,and meta-regression were performed to evaluate the efficacy of IGB on homeostasis model assessment of insulin resistance(HOMA-IR),alanine aminotransferase(ALT),aspartate aminotransferase(AST),and gamma-glutamyl transpeptidase(GGT),and to identify patients most appropriate for IGB therapy.Results:Thirteen observational studies and one randomized controlled trial met the inclusion criteria(624 participants in total).In the overall estimate,IGB therapy significantly improved the serum markers change from baseline to follow-up[HOMA-IR:1.56,95%confidence interval(CI)=1.16–1.95;ALT:11.53 U/L,95%CI=7.10–15.96;AST:6.79 U/L,95%CI=1.69–11.90;GGT:10.54 U/L,95%CI=6.32–14.75].In the stratified analysis,there were trends among participants with advanced age having less change in HOMA-IR(1.07 vs.1.82).The improvement of insulin resistance and liver biochemistries with swallowable IGB therapy was no worse than that with endoscopic IGB.Multivariate meta-regression analyses showed that greater HOMA-IR loss was predicted by younger age(p=0.0107).Furthermore,effectiveness on ALT and GGT was predicted by basal ALT(p=0.0004)and GGT(p=0.0026),respectively.Conclusions:IGB is effective among the serum markers of MAFLD.Younger patients had a greater decrease of HOMA-IR after IGB therapy.

Effects on physiologic measures of appetite from intragastric balloon and endoscopic sleeve gastroplasty: results of a prospective study

Background: Endoscopic bariatric therapies can help address widening management gaps in obesity. Their ability to facilitate weight loss is largely tied to influences on appetite through perturbations of gastric emptying and accommodation. As these tools gain traction in obesity therapy, their physiologic underpinnings require exploration, which may enhance efficacy, tolerance, and patient-tailored care.Methods: We prospectively assessed consecutive subjects with fluid-filled intragastric balloons (IGBs) (n = 18) placed between October 2016 and June 2017 or underwent endoscopic sleeve gastroplasty (ESG) (n = 23) from March 2018 to June 2018. Patients underwent physiologic appraisal at 3 months with13C-spirulina-based gastric emptying breath test to determine time to half emptying (T50), as well as maximum tolerated volume (MTV) of a standard nutrient drink test. Changes in T50 and MTV at 3 months were compared with percent total body weight loss (%TBWL) at 3 and 6 months using best-fit linear regression.Results: The change in T50 at 3 months correlated with %TBWL at 3 months for IGB (P = 0.01) and ESG (P = 0.01) but with greater impact on %TBWL in IGB compared to ESG (R2 = 0.42vs. 0.26). Change in T50 at 3 months was predictive of weight loss at 6 months for IGB (P = 0.01) but not ESG (P = 0.11). ESG was associated with greater decrease in MTV compared to IGB (340.25 ± 297.97 mLvs. 183.00 ± 217.13 mL,P = 0.08), indicting an enhanced effect on satiation through decreased gastric accommodation. Changes in MTV at 3 months did not correlate with %TBWL for either IGB (P = 0.26) or ESG (P = 0.49) but trended toward significance for predicting %TBWL at 6 months for ESG (P = 0.06) but not IGB (P = 0.19).Conclusion: IGB and ESG both induce weight loss but likely through distinct gastric motor function phenotypes, and gastric emptying may predict future weight loss in patients with IGB.

Overview on the endoscopic treatment for obesity:A review

Obesity rates have increased,and so has the need for more specific treatments.This trend has raised interest in non-surgical weight loss techniques that are novel,safe,and straightforward.Thus,the present review describes the endoscopic bariatric treatment for obesity,its most recent supporting data,the questions it raises,and its future directions.Various endoscopic bariatric therapies for weight reduction,such as intragastric balloons(IGBs),aspiration therapy(AT),small bowel endoscopy,endoscopic sleeve gastroplasty,endoluminal procedures,malabsorption endoscopic procedures,and methods of regulating gastric emptying,were explored through literature sourced from different databases.IGBs,AT,and small bowel endoscopy have short-term effects with a possibility of weight regain.Minor adverse events have occurred;however,all procedures reduce weight.Vomiting and nausea are common side effects,although serious complications have also been observed.

Effect of domperidone therapy on nocturnal dyspeptic symptoms of functional dyspepsia patients

AIM:To investigate the incidence of nocturnal dyspeptic symptoms in patients with functional dyspepsia(FD) and whether prokinetic drugs can alleviate them. METHODS:Eighty-five consecutive Chinese patients with FD were included in this study.One week after single-blinded placebo run-in treatment,baseline nocturnal intragastric pH,bile reflux and nocturnal dyspeptic symptoms of eligible patients,including epigastric pain or discomfort,abdominal distention and belching, were investigated with questionnaires.Patients exhibiting nocturnal dyspeptic symptoms were randomly and double-blindly assigned to domperidone group or placebo group.Nocturnal intragastric pH and percentage of duodenogastric bile reflux time were determined after treatment. RESULTS:Of the 85 FD patients,2 females withoutnocturnal symptoms,who responded to placebo run-in treatment,were excluded from the study,30(36.1%) exhibited nocturnal dyspeptic symptoms with increased duodenogastric bile reflux time(intragastric bilirubin absorbance>0.14)and mean gastric pH(confirming the existence of bile reflux)(P=0.021,0.023) at night were included in the study.Of these 30 patients,21(70%)had overt nocturnal duodenogastric bile reflux,which was significantly higher than that of those without nocturnal symptoms(P=0.026).The 30 patients were allocated to domperidone group or placebo group(n=15).The nocturnal duodenogastric bile reflux and gastric pH were significantly decreased after domperidone treatment(P=0.015,0.021).The severity score of nocturnal dyspeptic symptoms was also significantly decreased after domperidone treatment (P=0.010,0.015,0.026),which was positively correlated with the reduced nocturnal bile reflux or gastric pH(r=0.736,0.784,0.753 or r=0.679,0.715,0.697, P=0.039,0.036,0.037 or P=0.043,0.039,0.040). CONCLUSION:A subgroup of Chinese FD patients show overt nocturnal dyspeptic symptoms,which may be correlated with the excessive nocturnal duodenogastric bile reflux.Domperidone therapy can alleviate these symptoms.

Oxytocin decreases colonic motility of cold water stressed rats via oxytocin receptors

AIM: To investigate whether cold water intake into the stomach affects colonic motility and the involvement of the oxytocin-oxytocin receptor pathway in rats.METHODS: Female Sprague Dawley rats were used and some of them were ovariectomized. The rats were subjected to gastric instillation with cold(0-4℃, cold group) or room temperature(20-25℃, control group) saline for 14 consecutive days. Colon transit was determined with a bead inserted into the colon. Colonic longitudinal muscle strips were prepared to investigate the response to oxytocin in vitro. Plasma concentration of oxytocin was detected by ELISA. Oxytocin receptorexpression was investigated by Western blot analysis. Immunohistochemistry was used to locate oxytocin receptors.RESULTS: Colon transit was slower in the cold group than in the control group(P < 0.05). Colonic smooth muscle contractile response to oxytocin decreased, and the inhibitory effect of oxytocin on muscle contractility was enhanced by cold water intake(0.69 ± 0.08 vs 0.88 ± 0.16, P < 0.05). Atosiban and tetrodotoxin inhibited the effect of oxytocin on colonic motility. Oxytocin receptors were located in the myenteric plexus, and their expression was up-regulated in the cold group(P < 0.05). Cold water intake increased blood concentration of oxytocin, but this effect was attenuated in ovariectomized rats(286.99 ± 83.72 pg/mL vs 100.56 ± 92.71 pg/mL, P < 0.05). However, in ovariectomized rats, estradiol treatment increased blood oxytocin, and the response of colonic muscle strips to oxytocin was attenuated.CONCLUSION: Cold water intake inhibits colonic motility partially through oxytocin-oxytocin receptor signaling in the myenteric nervous system pathway, which is estrogen dependent.

Organization of future training in bariatric gastroenterology

A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the longterm impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a longterm approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicated obesity.

New Era: Endoscopic treatment options in obesity–a paradigm shift

The prevalence of obesity continues to rise,and along with it comes a multitude of health-related consequences.The healthcare community has consistently struggled with providing treatment options to obese patients,in part due to the reluctance of patients in pursuing the more effective(yet invasive)surgical approaches such as sleeve gastrectomy and Rou-en-Y gastric bypass.On the other hand,the less invasive approach such as lifestyle/behavioral interventions and pharmacotherapy(Orlistat,Phenteramine,Phentermine/Topiramate,Locaserin,Naltrexon/Buproprion,and Liraglutide)have very limited efficacy,especially in the morbidly obese patients.Despite our best efforts,the epidemic of obesity continues to rise and pose enormous costs on our healthcare system and society.Bariatric endoscopy is an evolving field generated to combat this epidemic through minimally invasive techniques.These procedures can be performed in an ambulatory setting,are potentially reversible,repeatable,and pose less complications than their invasive surgical counterparts.These modalities are designed to alter gut metabolism by means of space occupation,malabsorption,or restriction.In this review we will discuss different bariatric endoscopic options(such as intragastric balloons,endoscopic sleeve gastroplasty,endoscopic aspiration therapies and gastrointestinal bypass sleeves),their advantages and disadvantages,and suggest a new paradigm where providers may start incorporating this modality in their treatment approach for obese patients.

Current status of endoscopic sleeve gastroplasty: An opinion review

Bariatric surgeries have been demonstrated to be safe and effective treatment options for morbid obesity patients, but operative risks and high health care costs limit their clinical application. Endoscopic bariatric therapies are emerging as valuable alternatives for patients with doubts about bariatric surgery or ineligible for it. Endoscopic sleeve gastroplasty(ESG), a relatively novel technique of endoscopic bariatric therapies, has gained standing in the past few years. The safety, feasibility, repeatability, and potential for reversibility of ESG have been proven by multicenter studies. Compared to other weight loss strategies, current evidence demonstrates that ESG offers satisfactory efficacy in weight loss. Even though it is inferior to laparoscopic sleeve gastrectomy, it has lower risks of adverse events than surgical interventions and intragastric balloon within oneyear follow-up. Furthermore, ESG may be the ideal weight control strategy for patients who have poor adherence to behavioral interventions. Even so, trends in decreased weight loss effect over time, post-procedure weight regain, postprocedure gut hormone alteration, and possible effects of race and ethnicity on ESG still remain undetermined due to very limited reports and very short followups. Further clinical trials are required to validate and answer these questions.