This article reviews the evaluation and management of several gastrointestinal disorders that are commonly encountered by gastroenterologists and primary care physicians. With a focus on newer therapies, we discuss the management of chronic constipation, irritable bowel syndrome, Clostridioides difficile infection, gastroparesis, steatotic liver disease, and diverticulitis.

In the realm of gastroenterology, the inadequacy of current medical treatments for gastrointestinal (GI) motility disorders and inflammatory bowel disease (IBD), coupled with their potential side effects, necessitates novel therapeutic approaches. Neuromodulation, targeting the nervous system's control of GI functions, emerges as a promising alternative. This review explores the promising effects of vagal nerve stimulation (VNS), magnetic neuromodulation, and acupuncture in managing these challenging conditions. VNS offers targeted modulation of GI motility and inflammation, presenting a potential solution for patients not fully relieved from traditional medications. Magnetic neuromodulation, through non-invasive means, aims to enhance neurophysiological processes, showing promise in improving GI function and reducing inflammation. Acupuncture and electroacupuncture, grounded in traditional medicine yet validated by modern science, exert comprehensive effects on GI physiology via neuro-immune-endocrine mechanisms, offering relief from motility and inflammatory symptoms. This review highlights the need for further research to refine these interventions, emphasizing their prospective role in advancing patient-specific management strategies for GI motility disorders and IBD, thus paving the way for a new therapeutic paradigm.

Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.

Gastroparesis is a complex, challenging gastrointestinal disorder presenting with upper gastrointestinal symptoms, especially nausea and vomiting, with significant impact on patients' quality of life. After ruling out mechanical obstruction, it is essential to identify delay in gastric emptying for definitive diagnosis. The most common causes are idiopathic (no identified etiology), diabetes mellitus, and postsurgical status. Management of gastroparesis focuses on dietary modifications and treatment directed to symptom relief. Unfortunately, approximately one-third of patients are refractory to pharmacological therapy, and the effectiveness of the few nonpharmacological options has been questioned.

Extensive review of the literature identifies several uncertainties or controversies regarding the differential diagnosis based on the spectrum of symptoms, the lack of availability of reliable diagnostic test, and questions regarding effective therapeutic options. In this review, we discuss ten controversies regarding gastroparesis: clinical presentation, diagnosis, overlap syndromes, pathophysiology, etiology, as well as pharmacological and nonpharmacological therapeutic options. In addition, we briefly review studies exploring pathological, inflammatory, and molecular disturbances affecting the intrinsic neuromuscular elements that may be involved in the pathophysiology of gastroparesis and may constitute possible therapeutic targets in the future. Finally, we tabulate future research opportunities to resolve these controversies in the management of patients with gastroparesis.

Background The symptoms of gastroparesis, such as bloating, postprandial fullness, early satiety, nausea, and abdominal discomfort, progressively worsen the quality of life of the affected individuals. The diagnosis is established on the assessment of gastric function that confirms delayed gastric emptying in the absence of structural etiologies. This study aimed to detect gastroparesis-related clinical symptoms early in patients with type 2 diabetes mellitus (T2DM), investigate the concomitant risk factors, and evaluate the prevalence. Methodology This study was conducted at the Department of Medicine and Diabetes Outdoor Clinic of Sheikh Zayed Hospital, Rahim Yar Khan from February 13, 2022, to February 11, 2023. The study involved 175 patients with T2DM who reported gastroparesis-related symptoms. The demographic and clinical characteristics, symptom severity, complications, related risk factors, duration of disease, medications, body mass index (BMI), fasting plasma glucose, and glycated hemoglobin (HbA1C) levels were assessed. The severity of diabetic gastroparesis was established using the disease-specific Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) and the Gastroparesis Cardinal Symptom Index (GCSI). The five-point scale of the PAGI-SYM and the four-degree severity scores of GCSI were assessed. Neuropathy disability scores and motor evacuation functions were analyzed. Data were analyzed from these questionnaires, special proforma, and patient interviews. Results The clinical features of diabetic gastroparesis were observed in 44% of T2DM patients with mild-grade gastroparesis in 38 (21.7%), moderate in 30 (17.1%), and severe-grade gastroparesis-related symptoms in nine (5.2%) patients. The main manifestations were early satiety (45.1%), stomach fullness (44.5%), bloating (38.3%), and nausea (33.1%). Diabetic gastroparesis symptoms were considerably linked to disease duration of more than 10 years (p = 0.02), high HbA1c (p = 0.001), increased fasting blood glucose (p = 0.003), polyneuropathy, cigarette smoking, and history of comorbid conditions (p = 0.009). Obesity and the female gender were the forecasters of the manifestation of at least one cardinal gastroparesis symptom. Conclusions Gastric emptying is significant in the pathogenesis of gastroparesis-related symptoms. Disease duration of more than 10 years, poor glycemic control with hyperglycemia, high HbA1C, polyneuropathy, and cigarette smoking must be considered as predictors for early detection and risk factors for the advancement of gastroparesis in T2DM. Gastroparesis-related common symptoms of early satiety, bloating, and stomach fullness were considerably linked to the additional risk factors of hypercholesteremia, chronic microvascular complications, concomitant cardiovascular diseases, and a positive family history of diabetes mellitus. There was no relationship between BMI, age, types of treatment, and the degree of gastroparesis severity. The prevalence and severity of gastroparesis symptoms were particularly high among obese females with poor glycemic control and longer disease duration.

Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.

Gastroparesis (GP) occurs in patients after upper gastrointestinal surgery, in patients with diabetes or systemic sclerosis and in idiopathic GP patients. As pyloric dysfunction is considered one of the underlying mechanisms, measuring this mechanism with EndoFLIP™ can lead to a better understanding of the disease.

Between November 2021 and March 2022, we performed a retrospective single-centre study of all patients who had non-surgical GP, post-surgical GP and no sign of GP after esophagectomy and who underwent our post-surgery follow-up program with surveillance endoscopies and further exams. EndoFLIP™ was used to perform measurements of the pylorus, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling.

We included 66 patients, and successful application of the EndoFLIP™ was achieved in all interventions (n = 66, 100%). We identified 18 patients suffering from non-surgical GP, 23 patients suffering from GP after surgery and 25 patients without GP after esophagectomy. At 40, 45 and 50 ml balloon filling, the mean distensibility in gastroparetic patients was 8.2, 6.2 and 4.5 mm²/mmHg; 5.4, 5.1 and 4.7 mm²/mmHg in post-surgical patients suffering of GP; and 8.5, 7.6 and 6.3 mm²/mmHg in asymptomatic post-surgical patients. Differences between symptomatic and asymptomatic patients were significant.

Measurement with EndoFLIP™ showed that asymptomatic post-surgery patients seem to have a higher pyloric distensibility. Pyloric distensibility and symptoms of GP seem to correspond.

Autonomic neuropathy in patients with diabetes mellitus, and especially complications related to gastrointestinal neuropathy, are often overlooked in the clinic. Diabetic gastroenteropathy affects every segment of the gastrointestinal tract and generates symptoms that may include nausea, early satiety, vomiting, abdominal pain, constipation, and diarrhea. Severe cases can be complicated by weight loss, dehydration, and electrolyte disturbances. The pathophysiology is complex, the diagnostics and treatment options are multidisciplinary, and there is generally a lack of evidence for the treatment options. The aims for this review are first to summarize the pathophysiology and describe possible and expected symptoms and complications.Further, we will try to supply the clinician with a straightforward tool for diagnostics, and then, we shall summarize established treatment options, including diet recommendations, pharmacological and non-pharmacological options. Finally, we will explore the multiple possibilities of novel treatment, looking at medications related to the pathophysiology of neuropathy, other manifestations of autonomic neuropathies, and symptomatic treatment for other gastrointestinal disorders, also including new knowledge of endosurgical and neuromodulatory treatment. The overall goal is to increase awareness and knowledge on this frequent diabetic complication and to provide better tools for diagnosis and treatment. Ultimately, we hope to encourage further research in this field, as there are clear shortcomings in terms of biomarkers, pathophysiology, as well as treatment possibilities. In conclusion, diagnosis and management of diabetic gastroenteropathy are challenging and often require multidisciplinary teams and multimodal therapies. Treatment options are sparse, but new pharmacological, endoscopic, and neuromodulatory techniques have shown promising results in initial studies.

Gastroparesis is a neuromuscular disorder whose hallmark is delayed gastric emptying. It is a global challenge to the healthcare system because of poor treatment satisfaction for both the patients and clinicians, eventually leading to a reduction in the quality of life, with antecedent anxiety and depression. Although it is multifactorial in origin, diabetic, idiopathic, and drug-induced gastroparesis are the major risk factors. Disrupted interstitial cells of Cajal (ICC) and gastric dysrhythmia are pivotal to the pathogenesis, with most of the investigations targeted toward assessing gastric emptying and accommodation usually affected by distorted ICC and other neural networks. The treatment challenges can be overcome by a multidisciplinary approach involving gastroenterologists, gastrointestinal surgeons, biomedical engineers, nutritionists, psychologists, nurses, radionuclide radiologists, pharmacists, and family physicians. The exploration of the fundamental physiological processes underlying gastroparesis with the use of biomechanical materials should be given more attention by biomedical engineers to integrate innovative engineering with medicine for solving complex medical issues.

Gastrointestinal muscular sampling is useful in the histological assessment of functional gastrointestinal disorders. We devised a new sampling method to obtain a large volume of muscle tissues and then investigated the feasibility and safety of endoscopic muscular resection with a ligation device in an in vivo porcine model.

After establishing a submucosal tunnel, a rubber band was placed on the muscle tissue by sucking the exposed muscle layer. Thereafter, the established pseudopolyp was removed using an electrocautery snare, and the entry site of the submucosal tunnel was closed endoscopically. This procedure was performed at three sites in the esophagus and stomach of two pigs. The technical success, histology, and survival rate on postoperative day 7 were examined postoperatively.

We successfully completed the mentioned procedure in 11 of the 12 sites (92%), without the occurrence of severe adverse events. The median diameters of obtained tissues from the esophagus and stomach, respectively, were 5 mm and 10 mm. Histologically, both the inner and outer muscle layers were included in all specimens. The postprocedural course was found uneventful in both pigs during the observatory period.

Endoscopic muscular resection using a ligation device enabled us to obtain large and thick muscle tissue samples. This approach may facilitate more precise histological assessments of functional gastrointestinal disorders.

Gastroparesis or gastric stasis is the delayed transit of the ingested contents through the stomach in the absence of mechanical obstruction. It can have multiple etiologies, most commonly idiopathic (ID) and diabetic (DM). Gastroparesis can cause significant distress to patients as it leads to symptoms like intractable nausea and vomiting, weight loss, abdominal bloating, early satiety, etc. The pathogenesis is mainly thought to be due to the dysfunction of the gastric pacemaker cells, i.e., interstitial cells of Cajal (ICC), and their interaction with the other gastric motor function regulatory components. There are several proposed treatment options for gastroparesis. Despite that, most patients remain refractory to medical treatment and require additional interventions for symptomatic relief. One such intervention is gastric electrical stimulation or gastric pacemaker, which aids in improving gastric motility. We have searched PubMed, PubMed Central (PMC), Medline, Science Direct, and Google Scholar for articles pertaining to the use of gastric electrical stimulation in gastroparesis published in the last 10 years. The keywords used include "gastroparesis", "gastric stasis", "gastric pacemaker'', "gastric electrical stimulation", "nausea", "vomiting", "abdominal bloating", "gastric neuromodulation". We have finally included twelve studies that were the most relevant to our research question and met the quality assessment criteria. Exclusion criteria consisted of pediatric population studies, studies conducted on animals, books, and grey literature. Overall, these twelve studies helped evaluate the impact of gastric pacemakers on symptoms of gastroparesis like nausea, vomiting, weight loss, abdominal bloating, and quality of life. We found that most studies favored gastric pacemakers, improving the incidence of nausea and vomiting in patients with gastroparesis. There was a marked improvement in the BMI as well. On the other hand, most open-labeled studies showed improved quality of life and Gastroparesis Cardinal Symptom Index (GCSI) scores, while randomized controlled trials and meta-analyses did not reflect the same result. In addition, some other parameters improved with gastric pacemakers, Inflammatory markers, insulin levels (especially in diabetics), and the number of hospitalizations. In conclusion, gastric pacemaker is a potential treatment option for patients with medically refractory gastroparesis. As noted from the results of our study, nausea/vomiting, weight loss, and overall GCSI scores have shown marked improvement with gastric electrical stimulation (GES). Nevertheless, more extensive research is needed to understand better the full extent of this device's use as a viable treatment option for patients suffering from gastroparesis.

We present a case of severe gastroparesis in a recipient of orthotopic heart transplantation. Although a rare condition after heart transplantation, it is a potential cause of significant morbidity, including vomiting, aspiration and pneumonia. Moreover, impaired gastric emptying alters the pharmacokinetics of immunosuppressive medication with increased risk of severe side effects. Herein, we describe a diagnostic and therapeutic strategy that was successfully applied in a patient with gastroparesis.

Neurogastroenterology refers to the study of the extrinsic and intrinsic nervous system circuits controlling the gastrointestinal (GI) tract. Over the past 5-10 yr there has been an explosion in novel methodologies, technologies and approaches that offer great promise to advance our understanding of the basic mechanisms underlying GI function in health and disease. This review focuses on the use of optogenetics combined with electrophysiology in the field of neurogastroenterology. We discuss how these technologies and tools are currently being used to explore the brain-gut axis and debate the future research potential and limitations of these techniques. Taken together, we consider that the use of these technologies will enable researchers to answer important questions in neurogastroenterology through fundamental research. The answers to those questions will shorten the path from basic discovery to new treatments for patient populations with disorders of the brain-gut axis affecting the GI tract such as irritable bowel syndrome (IBS), functional dyspepsia, achalasia, and delayed gastric emptying.