Citations

Abstract The aims of this review are to appraise the role of the stomach in satiation, the effects of incretin and other hormone agonists on weight loss and the role of altered gastric functions in their effects on obesity or glycaemic control. In addition to the gut in its role in enzymatic digestion and hormonal responses to nutrient ingestion, gastric motor functions include accommodation, trituration and emptying [gastric emptying (GE)] of food and elicitation of postprandial satiation and satiety. The postprandially released hormones most extensively studied and utilized therapeutically are glucagon‐like peptide 1 (GLP‐1) and glucose‐dependent insulinotropic peptide (GIP). Their mechanisms of action include stimulation of pancreatic β cells to produce insulin. However, GLP‐1 reduces glucagon and slows GE, whereas GIP increases glucagon and does not alter GE. Molecular modifications of GLP‐1 (which has a T 1/2 of 3 min) led to the development of long‐acting subcutaneous or oral pharmacological agents that have been approved for the treatment of obesity, and their effects on gastric function are documented. Other medications in development target other molecular mechanisms, including glucagon and amylin. Small‐molecule GLP‐1 receptor agonists are promising for the treatment of obesity and may also slow GE. Bariatric surgery and endoscopy increase satiation by restricting gastric size; in addition Roux‐en‐Y gastric bypass and to a lesser extent sleeve gastrectomy (but not endoscopic gastroplasty) increase postprandial circulating incretins, reducing appetite. In conclusion the stomach's function is integral to the impact of the most effective pharmacological and procedural reversal of obesity related to the incretin revolution. image

AbstractIntroductionThe American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index‐Daily Diary (ANMS GCSI‐DD) is a patient‐reported outcome (PRO) instrument for gastroparesis. This study evaluated the psychometric properties of the ANMS GCSI‐DD and determined a meaningful change threshold using the data from a phase 2b trial in adults with moderate‐to‐severe idiopathic or diabetic gastroparesis (DG).MethodsThe psychometric properties of ANMS GCSI‐DD were analyzed using other clinician‐ and patient‐reported outcomes from 242 patients during the 12‐week trial. Trial exit interviews were conducted in a cohort of 32 patients to capture their perspectives on meaningful change from the trial.ResultsANMS GCSI‐DD demonstrated good performance: unidimensionality scores exhibited good fit; internal consistency reliability was >0.70; test–retest reliability was above 0.90, and convergent validity showed strong correlations (0.70–0.90) with overall severity rating and moderate correlations (0.30–0.70) with other outcomes. ANMS GCSI‐DD scores discriminated among groups with varying severity of gastroparesis symptoms in known‐groups validity (p < 0.001) and were responsive to symptom improvement. Triangulation of the quantitative anchor‐based estimates of 0.9–1.4 category points as a meaningful change in the ANMS GCSI‐DD composite score, and the qualitative exit interview findings of 0.5–1.5 as meaningful change, supports a one‐point change on a five‐point scale (0–4) as the meaningful change threshold.ConclusionThe ANMS GCSI‐DD is a reliable and valid PRO instrument to employ in clinical development for patients with moderate‐to‐severe idiopathic or DG, and a one‐point score change in the ANMS GCSI‐DD composite score is recommended as a meaningful change threshold of symptom change.

INTRODUCTION: To review stool diagnostic tests in acute and chronic diarrhea. METHODS: Narrative review of published literature. RESULTS: In acute diarrhea, stool tests are indicated when there is strong pretest probability of infectious etiology or Clostridioides difficile infection suggested by > 3 unformed bowel movements per 24 hours, symptoms lasting >7 days, and circumstances that are suggestive of infection. Several commercially available rapid tests for bacterial, viral, or protozoal infections may be offered in addition to traditional methods (e.g. culture, microscopy) and provide a result within 6 hours. For C . difficile infections, a highly sensitive test such as glutamate dehydrogenase test is required; however, this does not distinguish infection from carrier state. That differentiation requires specialized nucleic acid amplification test (for toxin B) or enzyme immunoassays for toxin A or B, which are unfortunately not generally offered by microbiology laboratories. Chronic diarrhea may result from inflammatory, fatty, osmotic, or secretory causes; the commonest cause is diarrhea-predominant irritable bowel syndrome/functional diarrhea. Current recommendations in societal guidelines or clinical practice updates regarding stool tests in diarrhea-predominant irritable bowel syndrome/functional diarrhea in the absence of alarm symptoms include testing for Giardia, calprotectin, fecal immunochemical test, and bile acid diarrhea. Comprehensive stool biochemical analyses (osmolality, pH, electrolytes) differentiate osmotic from secretory diarrhea and identify laxative abuse. Specific stool diagnostic tests for bile acid diarrhea and exocrine pancreatic insufficiency can lead to specific diagnosis and treatments. Surrogate markers associated with high fecal output and rapid transit in chronic diarrhea are stool form and colonic transit. DISCUSSION: Fecal testing is still very relevant in the practice of gastroenterology and deserves introduction of advanced microbiological and biochemical tests.