More Bypass => More Satiety => Less Food Intake

In a model of direct glucose delivery to the hindgut, the length of foregut bypassed directly correlated with degree of GLP-1 increase and ghrelin decrease.[52]

Amplify’d from bariatrictimes.com

In a model of direct glucose delivery to the hindgut, the length of foregut bypassed directly correlated with degree of GLP-1 increase and ghrelin decrease.[52]

Many diet modifications and metabolic surgical techniques have relied on the up-regulation of GLP-1 and peptide YY to exert a strong satiating effect. Exenatide is the first of the antidiabetic drugs related to GLP-1 to receive FDA approval, and its use has shown improvement in diabetes as well as modest weight loss.[51] Intestinal resection or bypass in patients is accompanied by a GLP-1 and PYY surge to meal stimulus that contributes to decreased food intake and improved glucose homeostasis.[35,39] In a model of direct glucose delivery to the hindgut, the length of foregut bypassed directly correlated with degree of GLP-1 increase and ghrelin decrease.[52] Clinically, this correlates to operations with a “malabsorptive” component achieving greater overall weight loss and diabetes resolution.[50] Sleeve gastrectomy seems unique in that increased gastric emptying contributes to less mechanical breakdown of food and resultant greater hindgut stimulation than seen with other purely restrictive procedures.[16]

Hindgut Hormones: Glugagon-Like Peptide (GLP-1) and Peptide-YY (PYY) The “ileal brake” was recognized clinically as the strong feeling of satiation that developed once nutrients reached the hindgut. This phenomenon makes evolutionary sense because further ingestion of food in the presence of nutrients within the distal small bowel would only result in calorie loss in the stool. To prevent this, the hindgut L-cells within the terminal ileum and colon produce GLP-1 and peptideYY to stop ingestion and improve nutrient utilization. GLP-1 is a potent stimulator of insulin secretion and is trophic to beta cell function.[2] It is the hormone believed to play a key role in diabetes resolution after gastric bypass and duodenal switch, but is also likely to be the culprit behind the rare hypoglycemic hyperinsulimia reported after these operations.[48] Both peptideYY and GLP-1 have receptors in the central satiety and metabolism centers, where they exert strong effects to terminate hunger and increase the basal metabolic expenditure rate. Obese and diabetic patients seem to release less circulating GLP-1 and peptide YY in repsonse to a meal than their lean counterparts.[35,49] This is likely because many obese people are “early-intestine dominant” with an excessively long small bowel that is too efficient at processing and absorbing calories. This leaves little residual intraluminal nutrients downstream to stimulate the release of hindgut hormones.[50] Read more at bariatrictimes.com

 

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New study Lap band => DECREASE in PYY => May drive patients to try to eat more!!!

The satiety hormone peptide YY as a regulator of appetite.



More PYY => Less Food Eaten



New study Lap band => DECREASE in PYY => May drive patients to try to eat more!!!



PYY reduction in obese subjects is associated with decreased satiety and increased food intake. Obese subjects have a PYY deficiency that reduces satiety and leads to excess food intake.



After gastric Bypass PYY is significantly elevated accompanied by a significant decrease in hunger and a significant increase in satiety (P < 0.05) after meal intake.



www.ncbi.nlm.nih.gov/pubmed/18441153by RP Vincent - 2008

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Unknown hormonal and neural satiety signals are thought to drive sustainable weight loss following laparoscopic adjustable gastric banding (LAGB).

A cross-sectional study examined 17 postoperative individuals who had already achieved a mean of 28% LAGB-induced weight loss (range, 10-38%). A prospective study assessed plasma PP and PYY meal responses in 16 obese individuals prior to LAGB.

Fasting PYY levels, however, were significantly lower in the postoperative group compared to the group tested pre-operatively, or the BMI-matched controls (-30%, p = 0.03).

PYY appears reduced in proportion to weight loss following LAGB, possibly representing attempted orexigenic homeostatic compensation. Read more at www.ncbi.nlm.nih.gov

 

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Slower Transit Time = Greater Absorbtion

Slower Transit Time = Greater Absorbtion

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Dig Dis Sci. 1995 May;40(5):1024-34. Effects of enteral feedback inhibition on motility, luminal flow, and absorption of nutrients in proximal gut of minipigs. Huge A, Weber E, Ehrlein HJ. Source Institute of Zoophysiology, University of Hohenheim, Stuttgart, Germany. Abstract We wanted to clarify whether the postprandial intestinal feedback control activated by nutrients in the distal gut exerts different effects on motility, transit of digesta, and absorption of nutrients in the proximal gut. Additionally, interrelationships among motility, transit, and absorption were to be elucidated because these relationships have only been investigated in the fasted state. In five minipigs, a 150-cm segment of the proximal jejunum was isolated by two cannulas. Motility of the jejunal segment was recorded by multiple strain gauges and analyzed by computerized methods. Markers (Cr- and Cu-EDTA) were used for the measurement of the flow rate, transit time, and absorption of nutrients. After a meal, the test segment was perfused with 2 kcal/min of an elemental diet over a period of 90 min. A feedback inhibition was activated by infusion of nutrients into the midgut at rates of 1-4 kcal/min. Saline was infused as control. With increasing energy loads infused into the midgut, the motility index and the length of contraction waves decreased, whereas the incidence of stationary contractions increased, ie, the motility changed from a propulsive to a segmenting pattern. These modulations of motility were associated with a linear decrease in the flow rate and a linear increase in transit time. Flow and transit were linearly correlated with each other. Additionally, the reduction in flow rate and the delay in luminal transit were associated with a linear increase in the absorption of nutrients. However, the increase in absorption induced by the feedback mechanism was small (7.3-13.4%) compared to the marked inhibition of the motility parameters (54-64%), the flow rate (59%), and the delay of transit (5.8-fold). Feedback control primarily modulated motor patterns and luminal flow, whereas the small increase in absorption was only a side effect due to the longer contact time of the nutrients with the mucosa. Read more at www.ncbi.nlm.nih.gov

 

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Dietary fibers affect stool weight and transit time.

Dietary fibers affect stool weight and transit time.

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Use of fiber instead of laxative treatment in a geriatric hospital to improve the wellbeing of seniors. Sturtzel B, Mikulits C, Gisinger C, Elmadfa I. Source Department of Nutritional Science, University of Vienna, Vienna, Austria. Abstract INTRODUCTION: Constipation is a common problem in the elderly population, especially in geriatric wards. Laxatives are the most preferred solution but current studies link constipation and laxative use to weight-loss and malnutrition in nursing homes. Dietary fibers also affect stool weight and transit time. So, oat-bran effectiveness in reducing the need for bowel medication and weight-loss for geriatric care patients was examined in a geriatric hospital. AIM: To determine whether the addition of oat-bran to common oral diet can reduce the use of laxatives and improve the wellbeing and bodyweight of the inhabitants of a long-term-care facility. METHODS: The study was designed as a controlled blind intervention trial among 30 frail inhabitants of a geriatric hospital aged 57-100 years with laxative use. Including criteria were: oral food intake and laxatives as therapy and excluding criteria were: parenteral and enteral feeding, surgeries in the gastro- intestinal tract, drugs that shorten or lengthen the passage through the gut, risk of aspiration, swallowing troubles. An intervention and a control group were formed. 15 of them received 7-8 g oat-bran/d for 12 weeks (fiber group) mixed up in the daily common diet of the ward and 15 served as control (control group). Data collection: Bodyweight was taken at baseline, after 6 weeks and at the end of the supplementation. Data on laxative use, stool frequency and the eating habits of the elderly were recorded. RESULTS: Laxatives were successfully discontinued by 59% (p < 0.001) in the fiber-group; in the control-group there was an increase of 8% (p=0.218). Bodyweight remained constant in the fiber-group and decreased in the control-group (p=0.002). The oat-fiber supplementation in the introduced form was well tolerated. CONCLUSIONS: Use of oat-fiber allowed discontinuation of laxatives by 59% while improving body-weight and wellbeing of the seniors. Fiber supplementation is a safe and convenient alternative to laxatives in a geriatric hospital. Read more at www.ncbi.nlm.nih.gov

 

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SmartPill® for the measurement of gastrointestinal transit time

Wireless motility device (SmartPill®) for the measurement of gastrointestinal transit time

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Br J Nutr. 2011 May;105(9):1337-42. Epub 2010 Dec 8. The use of a wireless motility device (SmartPill®) for the measurement of gastrointestinal transit time after a dietary fibre intervention. Timm D, Willis H, Thomas W, Sanders L, Boileau T, Slavin J. Source Department of Food Science and Nutrition, University of Minnesota, 1334 Eckles Avenue, St Paul, MN 55108, USA. Abstract Historically, measurement of gastrointestinal transit time has required collection and X-raying of faecal samples for up to 7 d after swallowing radio-opaque markers; a tedious, labour-intensive technique for both subjects and investigators. Recently, a wireless motility capsule (SmartPill®), which uses gut pH, pressure and temperature to measure transit time, has been developed. This device, however, has not been validated with dietary interventions. Therefore, we conducted a controlled cross-over trial to determine whether the device could detect a significant difference in transit time after ten healthy subjects (five men and five women) consumed 9 g of wheat bran (WB) or an equal volume, low-fibre control for 3 d. A paired t test was used to determine differences in transit times. Colonic transit time decreased by 10·8 (sd 6·6) h (P = 0·006) on the WB treatment. Whole-gut transit time also decreased by 8·9 (sd 5·4) h (P = 0·02) after the consumption of WB. Gastric emptying time and small-bowel transit time did not differ between treatments. Despite encouraging results, the present study had several limitations including short duration, lack of randomisation and unusable data due to delayed gastric emptying of the capsule. With minimal participant burden, the SmartPill technology appears to be a potentially useful tool for assessing transit time after a dietary intervention. This technology could be considered for digestive studies with novel fibres and other ingredients that are promoted for gut health. Read more at www.ncbi.nlm.nih.gov

 

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Narcotics increase Transit Time

Narcotics increase Transit Time

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Clin Pharmacol Ther. 1997 Apr;61(4):467-75. The safety and efficacy of oral methylnaltrexone in preventing morphine-induced delay in oral-cecal transit time. Yuan CS, Foss JF, Osinski J, Toledano A, Roizen MF, Moss J. Source Department of Anesthesia and Critical Care, University of Chicago, IL 60637, USA. cyuan@midway.uchicago.edu Abstract Methylnaltrexone is a quaternary opioid antagonist with limited ability to cross the blood-brain barrier that has the potential to antagonize the peripherally mediated gastrointestinal effects of opioids. In recent trials in human volunteers, we demonstrated that intravenous methylnaltrexone prevented morphine-induced changes in gastrointestinal motility and transit, without affecting analgesia. In this study, 14 healthy volunteers were first given three ascending oral doses of methylnaltrexone to obtain safety and tolerance data (phase A study). In phase B, these subjects were then given single-blind oral placebo and intravenous placebo, followed by randomized, double-blind oral placebo and intravenous morphine (0.05 mg/kg) or oral methylnaltrexone (19.2 mg/kg, an established highest and safe dose based on previous administrations of two smaller doses of 0.64 mg/kg and 6.4 mg/kg in phase A) and intravenous morphine (0.05 mg/kg). Oral-cecal transit time was assessed by the pulmonary hydrogen measurement technique after lactulose ingestion. Morphine significantly increased oral-cecal transit time from 114.6 +/- 37.0 minutes (mean +/- SD) to 158.6 +/- 50.2 minutes (p < 0.001). Oral methylnaltrexone (19.2 mg/kg) completely prevented morphine-induced increase in oral-cecal transit time (110.4 +/- 45.0 minutes; not significant compared with baseline; p < 0.005 compared with morphine alone). These sessions were then followed by single-blind evaluations of descending doses of methylnaltrexone. We observed that 6.4 mg/kg oral methylnaltrexone significantly attenuated the morphine-induced delay in oral-cecal transit time (p < 0.005 compared with morphine alone), and a dose-dependent response was obtained. There was no correlation between oral methylnaltrexone effects on the transit time and the drug plasma concentration, suggesting direct preferential luminal effects of oral methylnaltrexone. Oral methylnaltrexone may have a clinical value in the prevention and treatment of constipation induced by long-term opioid use. Read more at www.ncbi.nlm.nih.gov

 

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Beware Bowel Obstruction After RNY

Beware Bowel Obstruction After RNY

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Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review.

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen's space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB. Read more at www.ncbi.nlm.nih.gov

 

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15% Low Dose Aspirin suffer Upper Gastrointestinal Symptoms

Upper Gastrointestinal Symtoms (UGS) is a reason for discontinuation in patients treated by Low Dose Aspirin (LDA).



Fifteen percent of patients treated with Low Dose Aspirin suffered Upper Gastrointestinal Symptoms, mostly Gastroesophageal reflux symptoms which had a negative impact on daily life in 3 out of 4 patients and on treatment compliance in 1 out of 8 patients.

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Int J Cardiol. 2010 Nov 17. [Epub ahead of print] Prevalence and clinical impact of Upper Gastrointestinal Symptoms in subjects treated with Low Dose Aspirin: The UGLA survey. Cayla G, Collet JP, Silvain J, Thiefin G, Woimant F, Montalescot G. Source Institut de Cardiologie, Pitié-Salpêtrière Hospital, Paris, France. Abstract BACKGROUND: Upper Gastrointestinal Symtoms (UGS) is a reason for discontinuation in patients treated by Low Dose Aspirin (LDA). The nationwide UGLA survey was designed to evaluate the prevalence and the pattern of UGS in patients on LDA, to assess the independent correlates of UGS and finally to determine their impact on treatment compliance. METHODS: The UGLA survey was carried out on a representative sample of 10,000 subjects aged 50 or over. Prevalence and clinical impact of UGS related to LDA was appraised by standardised multi-choice questions. RESULTS: A total of 8106 propositus (8106/10,000) accepted to participate in the survey. Among them, 986 (12.2%) were treated with LDA. The prevalence of UGS was 15.4% in subjects on chronic LDA (152/986), 70% being gastroesophageal reflux (GER) (heartburn and/or regurgitation). UGS was reported to occur at least once a week in 60% of propositus (91/152) and daily life was reported to be moderately and severely impaired in 53% (81/152) and 20% (30/152) of them, respectively. UGS impacted compliance to treatment in 12% of propositus with UGS. A prior history of dyspeptic symptoms was predictive of LDA-related UGS (OR: 17.60; CI 95%: 11.52-26.88) whereas neither, gender nor aspirin dosage (ranging from 75 and 325mg) predicted the occurrence of UGS. CONCLUSIONS: Fifteen percent of patients treated with LDA suffered UGS, mostly GER symptoms which had a negative impact on daily life in 3 out of 4 patients and on treatment compliance in 1 out of 8 patients. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved. Read more at www.ncbi.nlm.nih.gov

 

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Ulcers in about one-third low-dose aspirin patients

Gastroduodenal ulcers/erosions were observed in about one-third of asymptomatic patients taking low-dose aspirin

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QJM. 2011 Feb;104(2):133-9. Epub 2010 Sep 24. Prevalence and independent factors for gastroduodenal ulcers/erosions in asymptomatic patients taking low-dose aspirin and gastroprotective agents: the OITA-GF study. Tamura A, Murakami K, Kadota J; OITA-GF Study Investigators. Collaborators (24) Goto Y, Kawano Y, Naono S, Sato T, Kotoku M, Abe T, Watada M, Anan J, Tanahashi J, Mizukami K, Yasaka S, Okimoto T, Kodama M, Miyamoto K, Watanabe T, Hino M, Shinozaki K, Zaizen H, Hisamatsu A, Soma W, Nakagawa Y, Nakashima H, Okawara H, Nagai T. Source Internal Medicine 2, Oita University, Idaigaoka 1-1, Hasama-machi, Yufu 879-5593, Japan. akira@oita-u.ac.jp Abstract BACKGROUND: Although it is well known that aspirin causes gastroduodenal mucosal injury and that aspirin-induced gastroduodenal mucosal injury is often asymptomatic, the prevalence and independent factors for gastroduodenal mucosal injury have not been clarified in asymptomatic patients taking low-dose aspirin and gastroprotective agents. AIM: To clarify the prevalence and independent factors for gastroduodenal ulcers/erosions in asymptomatic patients taking low-dose aspirin and gastroprotective agents. DESIGN: Prospective observational study. METHODS: We performed endoscopy in 150 asymptomatic patients taking low-dose aspirin and gastroprotective agents for at least 3 months. RESULTS: Gastroduodenal ulcers/erosions were observed in 37.3% [ulcers (4.0%); erosions (34.0%)]. Univariate logistic regression analyses showed that proton-pump inhibitor (PPI) use was negatively associated with gastroduodenal ulcers/erosions [odds ratio (OR) 0.35, 95% confidence interval (95% CI) 0.17-0.75, P=0.007]. A multivariate logistic regression analysis selected PPI use as the only independent factor for gastroduodenal ulcers/erosions (OR 0.35, 95% CI 0.14-0.86, P=0.02). None of the 53 patients with PPI use had any gastroduodenal ulcers, and 11 with standard-dose PPI use tended to have a lower prevalence of gastroduodenal erosions than 42 with low-dose PPI use (0% vs. 28.6%, P=0.052). CONCLUSION: Gastroduodenal ulcers/erosions were observed in about one-third of asymptomatic patients taking low-dose aspirin and gastroprotective agents, and PPI use was a negative independent factor for gastroduodenal ulcers/erosions in those patients. In addition, standard-dose PPI therapy might be more effective in the prevention of aspirin-induced gastroduodenal mucosal injury than low-dose PPI therapy. Read more at www.ncbi.nlm.nih.gov

 

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Low doses of aspirin increase chance of developing ulcers



Aspirin has long been hailed as one of the most effective, low-cost ways to help guard against a heart attack or stroke. However, international medical researchers caution that low doses of aspirin also increase a patient's chance of developing an ulcer, often without warning signs.



The JUPITER study measured the prevalence and incidence of gastroduodenal ulcers among 187 aspirin therapy patients from Australia, the United Kingdom, Canada and Spain.

It found one in ten people taking low-dose aspirin to prevent a stroke or heart attack had a stomach ulcer at any point in time, with older patients aged 70 years and over, as well as those infected with the bacterium 'Helicobacter pylori', three times more at risk.

"This study reveals a high prevalence of ulcers in patients prescribed low-dose aspirin for vascular protection - doses between 75-300 mg a day.

Amplify’d from www.news-medical.net

Low doses of aspirin increase chance of developing ulcers

Aspirin has long been hailed as one of the most effective, low-cost ways to help guard against a heart attack or stroke. However, international medical researchers caution that low doses of aspirin also increase a patient's chance of developing an ulcer, often without warning signs.

The JUPITER study measured the prevalence and incidence of gastroduodenal ulcers among 187 aspirin therapy patients from Australia, the United Kingdom, Canada and Spain.

It found one in ten people taking low-dose aspirin to prevent a stroke or heart attack had a stomach ulcer at any point in time, with older patients aged 70 years and over, as well as those infected with the bacterium 'Helicobacter pylori', three times more at risk.

"This study reveals a high prevalence of ulcers in patients prescribed low-dose aspirin for vascular protection - doses between 75-300 mg a day.

"Other similar studies have found people taking low doses of aspirin are about two to four times more likely to be hospitalised with an ulcer bleed. What has not been quite clear is whether this is due to aspirin patients actually getting ulcers more often, or just more likely to bleed from an ulcer that might be already there." Read more at www.news-medical.net

 

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