The evaluation of the patient with gastroparesis secondary to insulin-dependent diabetes mellitus.
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Biomedical subjects
Publications and source records attributed to R D Rothstein.
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Autoradiography was used to localize and quantify substance P receptors in the feline gastrointestinal tract. The specific binding of 125I-Bolton Hunter substance P was determined in the esophagus, lower esophageal sphincter, antrum, pylorus, duodenum, jejunum, ileum, ileocecal sphincter, and colon. Competitive binding studies indicated that substance P binding sites or NK-1 receptor sites were demonstrated. The concentration of NK-1 receptors was greatest in the distal half of the gastrointestinal tract, with the highest concentrations in the proximal colon. The circular muscle layer contained the greatest amount of substance P binding. The location and density of binding sites for substance P may be important in understanding the relative importance of both the pharmacological responses to this neuropeptide and the immunohistochemical evidence of the peptide at different sites in the intestine.
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The ileocecal sphincter in the cat demonstrates a reflex contraction to colonic distension. This study investigates the pathway mediating this reflex in the intact bowel using an in vivo model. The ileocecal sphincter (ICS) and distal ileal intraluminal pressures were recorded in fasted chloralose-anesthetized cats. Colonic balloon distension caused a slight, but significant, ileal inhibition with a maximum decrease from resting ileal pressure by 2.6 +/- 0.76 mmHg (P less than 0.005) to 3 ml distension. A volume-dependent contraction at the ICS was seen with a maximal contraction of 16.8 +/- 2.2 mmHg (P less than 0.005) with 4 ml distension. The reflex ICS contraction was inhibited by tetrodotoxin and phentolamine but not by bilateral cervical vagotomy, naloxone, atropine, or trimethaphan camsylate. The reflex contraction at the ICS was inhibited by substance P tachyphylaxis. Substance P tachyphylaxis did not inhibit ICS contraction to phenylephrine. The substance P antagonist, [DArg1,DTrp7,9,Leu11]substance P failed to antagonize substance P and failed to inhibit the ICS contractile response to colonic balloon distension. Spinal anesthesia inhibited this reflex. We have thus demonstrated that the ICS reflex contraction to colonic balloon distension in the intact bowel is mediated by an extrinsic spinal neural pathway involving both tachykinin and catecholamines as neurotransmitters.
Gastrointestinal motor abnormalities are common in patients with diabetes mellitus and may result in significant morbidity. Patients may present with a wide range of symptoms, including manifestations of organ involvement or poor glucose control. Derangements of motility may result in complicated and difficult management problems. This paper reviews the clinical features, pathophysiology, and treatment of diabetic gastrointestinal motility disorders.
UNLABELLED: Neurotensin, a neuropeptide identified in the distal small intestine, plays an unclear role in ileocecal sphincter regional function. The purpose of this study was to determine the effect and mechanism of action of neurotensin on the feline ileocecal sphincter (ICS), proximal colon, and distal ileum. Intraluminal pressures were recorded at these sites in anesthetized cats after superior mesenteric artery injection of neurotensin. Dose dependent tonic and phasic contractions were seen at all sites. Peak pressure responses were seen at the maximal dose used and were greater for the ICS than the distal ileum and the proximal colon. The threshold dose for peak pressures for neurotensin was 0.05 microgram/kg for all sites with the maximal peak pressures occurring at the maximal dose used (100 micrograms/kg). The motility index (MI [number of contractions x mean amplitude of contractions]) was determined for three minutes before and after neurotensin injection. The change in the motility index after neurotensin increased at doses above 0.05 micrograms/kg for the ileum and the ICS and 0.25 microgram/kg for the colon. Maximal responses for the motility index were seen at 1 microgram/kg for the distal ileum, and 10 micrograms/kg for the ICS and the proximal colon, with the greatest response seen at the ICS. Neurotensin-induced ICS relaxation was seen at 1 microgram/kg (50 +/- 10%, p less than 0.01) in 33% of cats. The contractile responses of the distal ileum and the proximal colon were not inhibited by naloxone, trimethaphan, tetrodotoxin, or atropine. The ICS contractile response was decreased by tetrodotoxin by 53%, p less than 0.05. The alpha 2 antagonist, yohimbine reduced the neurotensin induced ICS contraction from 31.6 +/- 3.4 to 21.9 +/- 3.3 mm Hg, p less than 0.05. Prazosin had no effect on neurotensin-induced contractions. In the presence of cimetidine and diphenhydramine, trimethaphan did not affect the neurotensin-induced contractile response at all three sites. However, neurotensin inhibited contractions induced by trimethaphan alone at all three sites. CONCLUSIONS: 1. Neurotensin causes a dose-dependent contractile response at the distal ileum, ICS, and proximal colon. 2. Neurotensin has an inhibitory effect at all three sites. 3. The contractile response at the distal ileum and the proximal colon is mediated via smooth muscle receptors. 4. The contractile response of neurotensin at the ICS is mediated partly via alpha 2 receptors and partly via smooth muscle receptors.
The purpose of this study was to determine the mechanism of action of substance P at the distal ileum, ileocecal sphincter (ICS), and proximal colon in the cat and to determine the localization of substance P receptors at these sites by autoradiography. Intraluminal pressures and myoelectric activity were recorded at the feline distal ileum, ICS, and colon. Substance P caused a tonic and phasic spike-dependent contractile response at all three sites. The antagonists propranolol, phentolamine, and naloxone did not affect the contractile response to substance P at the ileum, ICS, or colon. The ganglionic blocker trimethaphan camsylate potentiated the response to substance P at all three sites, P less than 0.05. Both atropine and tetrodotoxin reduced the response of substance P at the ileal site. At the ICS, atropine or tetrodotoxin reduced, but did not obliterate, the effect of substance P. Neither atropine nor tetrodotoxin reduced substance P-induced colonic contractions. By use of autoradiography, specific binding for substance P was determined to be present at all three sites with the greatest concentration of substance P receptors in the circular muscle layer. In conclusion, these studies suggest multiple sites of action of substance P. At the ileum, substance P causes contraction via a cholinergic pathway. At the ICS, substance P has an excitatory action through a cholinergic pathway and also at smooth muscle receptors. In the proximal colon, the excitatory action of substance P is via smooth muscle receptors. An inhibitory ganglionic pathway also exists at all three sites. Substance P receptors exist predominantly in the circular muscle region of the ileum, ICS, and the proximal colon.
Pain of esophageal origin includes heartburn, odynophagia, and spontaneous chest pain. The etiologic causes of esophageal chest pain are varied and include gastroesophageal reflux, esophagitis from radiation, infection, accidental ingestion, medication, and systemic disorders, and motility disorders. Useful tools in the evaluation of patients with suspected esophageal disease include endoscopy, manometry with provocative agents, and prolonged pH and pressure studies.
This report describes two patients with subacute pulmonary mucormycosis who died of pulmonary hemorrhage. Both patients had diabetes mellitus, but neither patient had the typical fulminant illness associated with this infection. The subacute progressive illness seen in these patients is unusual and suggests the need for aggressive diagnostic and therapeutic measures in patients who are at risk for this infection.