The pathophysiology of persistent gastrointestinal (GI) symptoms in patients with diabetic gastroparesis is poorly understood. Our aim was to evaluate gastric sensation and accommodation to a meal in patients with diabetic gastroparesis and refractory symptoms. We performed intermittent, phasic balloon distensions of the stomach using a gastric barostat device in 18 patients with diabetes and gastroparesis unresponsive to prokinetic therapy and in 13 healthy volunteers. We assessed the biomechanical, sensory and accommodation responses of the stomach, during fasting and after liquid meal. During balloon distension, the sensory thresholds for discomfort were lower (P < 0.02) in patients with diabetes than those in controls, in both the fasting and the postprandial states. The accommodation response to a meal was significantly impaired (P = 0.01) in patients with diabetes when compared to controls, although fasting gastric tone was similar (P = 0.08). Patients with diabetic gastroparesis and refractory GI symptoms demonstrate sensori-motor dysfunction of the stomach, comprising either impaired accommodation, gastric hypersensitivity or both. An objective evaluation of these biomechanical and sensory properties may provide valuable mechanistic insights that could guide therapy.

OBJECTIVES There is limited and conflicting data regarding the role of esophageal hypersensitivity in the pathogenesis of functional chest pain (FCP). We examined esophageal sensori-motor properties, mechanics and symptoms in subjects with FCP. METHODS Esophageal balloon distension test (EBDT) was performed using impedance planimetry in 189 (m/f = 57/132) consecutive subjects with noncardiac, non-reflux chest pain, and 36 (m/f = 16/20) healthy controls. The biomechanical and sensory properties of subjects with and without esophageal hypersensitivity were compared to controls. The frequency, intensity and duration of chest pain were assessed. RESULTS: 143 (75 %) subjects had esophageal hypersensitivity and 46 (25%) had normal sensitivity. Typical chest pain was reproduced in 105/143 (74%) subjects. Subjects with hypersensitivity demonstrated larger cross-sectional area (CSA) (p<0.001), decreased esophageal wall strain (p<0.001) and distensibility (p<0.001), and lower thresholds for perception (p<0.01), discomfort (p<0.01) and pain (p<0.01) compared to those without hypersensitivity or healthy controls. Chest pain scores (mean ± SD) for frequency, intensity and duration were 2.5 ± 0.3, 2.2 ± 0.2 and 2.2 ± 0.2 respectively, and were similar between the two patient groups. CONCLUSIONS 75% of subjects with FCP demonstrate esophageal hypersensitivity. Visceral hyperalgesia and sensori-motor dysfunction of the esophagus play a key role in the pathogenesis of chest pain.

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Mucormycosis is a rare, but emerging, life-threatening, rapidly progressive, angioinvasive fungal infection that usually occurs in immunocompromised patients. We present a case of pulmonary mucormycosis in a diabetic patient who was on chronic steroid therapy for ulcerative colitis. Early recognition of this diagnosis, along with aggressive management, is critical to effective therapy and patient survival. The delay in diagnosis of this rapidly progressive infection can result in mortality.

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The standard protocol for esophageal manometry involves placing the patient in the supine position with head turned to left (supine head left [SHL]) while evaluating liquid bolus swallows. Routinely, semisolid or solid boluses are not evaluated. Currently, the daily American diet includes up to 40% solid or semisolid texture. Thus far, the data on the effect of different bolus on high-resolution esophageal pressure topography (HREPT) parameters are scarce. This study aims to evaluate the effect of every day bolus consistencies in different body positions on HREPT variables. HREPT was performed on healthy volunteers with a modified protocol including liquid swallows in the SHL position followed by applesauce (semisolid), cracker (solid), and marshmallow (soft solid) in three different positions (SHL, sitting, and standing). A total of 38 healthy adult subjects (22 males and 16 females, median age = 27, and mean body mass index = 25) were evaluated. The resting upper esophageal sphincter pressure was significantly different while subjects swallowed crackers, applesauce, and marshmallows in most positions compared with liquid SHL (P < 0.05). The lower esophageal sphincter, contractile front velocity, and distal contractile integral pressures did not differ in all different consistencies compared with SHL. The integrated relaxation period was significantly higher with solid bolus compared with liquid bolus only in SHL position. The intrabolus pressure was significantly different with solid and soft solid boluses in all postures compared to liquid SHL. The American diet consistency affects upper esophageal sphincter pressure and partially integrated relaxation period and intrabolus pressure in various positions. Semisolid bolus swallows do not cause substantial pressure changes and are safe for evaluation and maintaining adequate caloric intake in patients with dysphagia who cannot tolerate solids.

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Body position significantly affects in the LES function and its measurements. HREPT when performed on standing position offers the best yield for detection of hiatal hernia and is superior to endoscopy or supine manometry.