Coinciding with the increasing rates of cannabis abuse has been the recognition of a new clinical condition known as Cannabinoid Hyperemesis Syndrome. Cannabinoid Hyperemesis Syndrome is characterized by chronic cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing. Cannabinoid Hyperemesis Syndrome occurs by an unknown mechanism. Despite the well-established anti-emetic properties of marijuana, there is increasing evidence of its paradoxical effects on the gastrointestinal tract and CNS. Tetrahydrocannabinol, cannabidiol, and cannabigerol are three cannabinoids found in the cannabis plant with opposing effects on the emesis response. The clinical course of Cannabinoid Hyperemesis Syndrome may be divided into three phases: prodromal, hyperemetic, and recovery phase. The hyperemetic phase usually ceases within 48 hours, and treatment involves supportive therapy with fluid resuscitation and anti-emetic medications. Patients often demonstrate the learned behavior of frequent hot bathing, which produces temporary cessation of nausea, vomiting, and abdominal pain. The broad differential diagnosis of nausea and vomiting often leads to delay in the diagnosis of Cannabinoid Hyperemesis Syndrome. Cyclic Vomiting Syndrome shares several similarities with CHS and the two conditions are often confused. Knowledge of the epidemiology, pathophysiology, and natural course of Cannabinoid Hyperemesis Syndrome is limited and requires further investigation.

Intrapyloric injection of botulinum toxin improves gastric emptying in patients with gastroparesis, although this benefit was not superior to placebo at 1 month. Also, in comparison to placebo, symptoms do not improve significantly by 1 month after injection. Overall, we are unable to recommend botulinum toxin therapy for widespread use in the treatment of delayed gastric emptying until more data are available.

SmartPill capsule assessment of gastric emptying and whole gut transit compares favorably with that of scintigraphy. Wireless capsule motility shows promise as a useful diagnostic test to evaluate patients for GI transit disorders and to study the effect of prokinetic agents on GI transit.

Epidemiological data have demonstrated that obesity is an important risk factor for the development of gastroesophageal reflux disease. There is also accumulating data that obesity is associated with complications related to longstanding reflux such as erosive esophagitis, Barrett's Esophagus, and esophageal adenocarcinoma. Central obesity, rather than BMI, appears to be more closely associated with these complications. Pathophysiological disturbances in obesity include esophageal motor disorders, lower esophageal sphincter abnormalities, a trend toward the development of hiatal hernia, increased intragastric pressure and increased gastric capacity. Additionally, alterations in the secretion of adiponectin and leptin from adipocytes is a proposed link between obesity and Barrett's esophagus and esophageal adenocarcinoma. Evidence to date suggest that bariatric surgery, specifically Roux-en-Y gastric bypass, can ameliorate reflux disease through loss of excess weight. Surgical data is confounded by the concomitant repair of prevalent hiatal hernias in many patients. The data for medical weight loss as a treatment for GERD is less robust, but there does appear to be an association with successful weight loss and fewer GERD symptoms.

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Nearly all epidemiologic studies have found an association between increasing body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD). Changes in gastroesophageal anatomy and physiology caused by obesity may explain the association. These include an increased prevalence of esophageal motor disorders, diminished lower esophageal sphincter (LES) pressure, the development of a hiatal hernia, and increased intragastric pressure. Central adiposity may be the most important risk for the development of reflux and related complications such as Barrett's esophagus and esophageal adenocarcinoma. Weight loss, through caloric restriction and behavioral modification, has been studied infrequently as a means of improving reflux. Bariatric surgery and its effects on a number of obesity-related disorders have been studied more extensively. Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms and findings of GERD. The mechanism of action through which this surgery is successful at improving GERD may be independent of weight loss and needs further examination. Current evidence suggests that laparoscopic adjusted gastric banding should be avoided in these patients as the impact on gastroesophageal reflux disease appears unfavorable.

The objectives of this study were to determine the clinical response to Enterra gastric electric stimulation (GES) in patients with refractory gastroparesis and to determine factors associated with a favorable response.Methods-This study was conducted in patients undergoing Enterra GES for refractory gastroparesis. Symptoms were scored before and after GES implantation using the Gastroparesis Cardinal Symptom Index (GCSI) with additional questions about abdominal pain and global clinical response.Results-During an 18-month period, 29 patients underwent GES implantation. Follow-up data were available for 28 patients, with average follow-up of 148 days. At follow-up, 14 of 28 patients felt improved, 8 remained the same, and 6 worsened. The overall GCSI significantly decreased with improvement in the nausea/vomiting sub-score and the post-prandial subscore, but no improvement in the bloating subscore or abdominal pain. The decrease in GCSI was greater for diabetic patients than idiopathic patients. Patients with main symptom of nausea/vomiting had a greater improvement than patients with the main symptom of abdominal pain. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript narcotic analgesics at the time of implant had a poorer response compared to patients who were not.Conclusions-GES resulted in clinical improvement in 50% of patients with refractory gastroparesis. Three clinical parameters were associated with a favorable clinical response: (1) diabetic rather than idiopathic gastroparesis, (2) nausea/vomiting rather than abdominal pain as the primary symptom, and (3) independence from narcotic analgesics prior to stimulator implantation. Knowledge of these three factors may allow improved patient selection for GES.

Background Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. Methods A cross-sectional review of patients presenting to twenty Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to, and after arrival in the ER. Primary mechanism of injury and clinical outcomes were analyzed. Results There were 231,694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males [OR= 2.62 (CI 1.98–3.47)]. The risk was also increased in African Americans [OR = 4.61 (CI 3.65–5.82)]. Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; p <0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; p <0.005). In logistic regression modeling, traumatic injury of the esophagus [OR=3.43 9 2.50–4.71)] and male gender [OR=1.52 (1.46–1.59)] were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality [OR = 1.10 (1.07–1.12)] but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39–1.83). Conclusions Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (~46%) and mortality (~20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.