Delayed Gastric Emptying Scintigraphy in Cystic Fibrosis Patients Before and After Lung Transplantation

doi:10.1016/j.healun.2006.04.013

The Journal of Heart and Lung Transplantation

Volume 25, Issue 9, September 2006, Pages 1077-1083

https://doi.org/10.1016/j.healun.2006.04.013 Get rights and content

Background

The purpose of this study was to assess the rate of gastric emptying (GE) in cystic fibrosis patients scheduled for lung transplantation.

Methods

Thirty patients (20 males, 10 females, 22.6 ± 6.4 years) were evaluated by GE scintigraphy before (1.58 ± 1.11 years) and early after (5.8 ± 2.6 weeks) heart–lung transplantation (n = 13) or lung transplantation (n = 17). Solid retention rates at 2 hours (RR2) and 3 hours (RR3) and half-emptying times (T50) of solids and liquids obtained before transplantation were compared with those after transplantation. Data were also compared with those obtained from a control group of 53 healthy volunteers.

Results

Before surgery, 20 patients (67%) showed a delayed GE (T50 of solids: patients 160.86 ± 59.21 minutes vs controls 75.43 ± 15.13 minutes, p < 0.0001), and 4 of them also had a delayed T50 of liquids. After surgery, the T50 of solids was considered unreliable (too much stasis) in 24 patients. Thus, analyses were done on the basis of solid retention rates. Twenty-nine patients (97%) showed very delayed GE compared with controls (p < 0.0001), 20 of whom also had a delayed T50 of liquids. RR2 and RR3 were significantly higher after surgery than before (RR2 = 86 ± 17% and RR3 = 77 ± 22% vs 50 ± 24% and 27 ± 24% after and before surgery, respectively, p < 0.0001). However, there was no correlation between pre- and post-transplantation scintigraphy results.

Conclusions

Delayed GE of solids was a frequent abnormality in patients with end-stage cystic fibrosis, with a dramatic delay after surgery in almost all patients. These results emphasize the need for early management of such patients by dietary manipulation or prokinetic medications.

Section snippets

Cystic Fibrosis Patients

Thirty patients (20 males, 10 females; age 22.6 ± 6.4 [mean ± SD] years at the time of pre-transplant staging) were examined before and after heart–lung (n = 13) or bilateral lung (n = 17) transplantation at the Hospital of the University of Nantes, France. At the time of scintigraphy, these patients were not taking any medications affecting the GI tract (these medications were stopped at least 4 days before scintigraphy), except for enteric-coated pancreatic enzymes and standard immune

Results

Table 2 and Figure 1 show the results of pre- and post-transplant scintigraphy tests. Using the mean ± 1.96 SD of the T50 values of solids and liquids obtained in controls as a 95% confidence interval of normality, patient GE data were stratified into two separate groups: those with a normal GE and those with an abnormal GE. However, when T50 was not evaluable, this classification was made on the basis of the mean ± 1.96 SD of RR2 and RR3 retention rates of solids obtained in controls (Table 1

Discussion

Before transplantation, GI manifestations of the disease are common in cystic fibrosis patients, most of them related to exocrine pancreatic insufficiency and hepatobiliary tract involvement, but their pathogeneses are complex. In 1996, Cucchiari et al used ultrasonography to measure the GE time of a solid–liquid meal in 29 patients.⁴ They recorded significantly delayed GE in 26 of 29 patients, compared with 13 healthy control subjects. Our results are in agreement with this first study, also

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Our findings lay the foundation for larger, controlled studies. As reported from multiple centers, one-quarter or more of lung transplant recipients develop gastroparesis.1-5 Several series have commented on various graft-related complications associated with gastroparesis.5,8
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Fifty-two lung transplant recipients underwent per-oral endoscopic pyloromyotomy for refractory gastroparesis. Gastroparesis was assessed by a pre–per-oral endoscopic pyloromyotomy and post–per-oral endoscopic pyloromyotomy radionuclide gastric emptying test and Gastroparesis Cardinal Symptom Index. Secondary outcomes included 90-day complications, gastroesophageal reflux as measured by pH testing, and longitudinal spirometry measurements.
Median time from lung transplant to per-oral endoscopic pyloromyotomy was 10.5 months. Twenty-eight patients had prior pyloric botulinum injection with either no improvement or relapse of symptoms. Post–per-oral endoscopic pyloromyotomy gastric emptying tests were available for 32 patients and showed a decrease in median gastric retention at 4 hours from 63.5% pre–per-oral endoscopic pyloromyotomy to 5.5% post–per-oral endoscopic pyloromyotomy (P < .0001). Complete normalization of gastric emptying time was noted in 19 patients. Gastroparesis Cardinal Symptom Index score significantly improved after per-oral endoscopic pyloromyotomy (median, 23-3.5; P < .0001). Post–per-oral endoscopic pyloromyotomy pH testing showed improved or stable DeMeester score in all patients except 1. Graft function (forced expiratory volume in 1 second) remained stable 1 year after per-oral endoscopic pyloromyotomy.
The improvements in symptom score and radionuclide imaging observed in this uncontrolled study suggest that per-oral endoscopic pyloromyotomy is an effective strategy in the lung transplant population and can be performed with minimal morbidity.
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A pediatric study reported that gastroparesis also has a strong impact on allograft survival.60 Patients with a previous history of gastroparesis, especially those with CF, are at higher risk of recurrent gastroparesis and other GI complications.57 Careful use of opioids for pain control is warranted in patients with CF as they are at risk for constipation and can easily develop distal intestinal obstruction syndrome in the early postoperative period with worsening gastroperesis.61
Pediatric lung transplantation is a highly specialized treatment option at a select few hospitals caring for children. Advancements in surgical and medical approaches in the care of these children have improved their care with only minimal improvement in outcomes which remain the lowest of all solid organ transplants. A crucial time period in the management of these children is in the perioperative period after performance of the lung transplant. Supporting allograft function, preventing infection, maintaining fluid balance, achieving pain control, and providing optimal respiratory support are all key factors required for this highly complex pediatric patient population. We review commonly encountered complications that these patients often experience and provide strategies for management.
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Cystic fibrosis (CF) is the indication for transplantation in approximately 15% of recipients worldwide, and Cystic Fibrosis Lung Transplant Recipients (CFLTRs) have excellent long-term outcomes. Yet, CFLTRs have unique comorbidities that require specialized care. The objective of this document is to provide recommendations to CF and lung transplant clinicians for the management of perioperative and underlying comorbidities of CFLTRs and the impact of transplantation on these comorbidities. The Cystic Fibrosis Foundation (CFF) organized a multidisciplinary committee to develop CF Lung Transplant Clinical Care Recommendations. Three workgroups were formed to develop focused questions. Following a literature search, consensus recommendations were developed by the committee members based on literature review, committee experience and iterative revisions, and in response to public comment. The committee formulated 32 recommendation statements in the topics related to infectious disease, endocrine, gastroenterology, pharmacology, mental health and family planning. Broadly, the committee recommends close coordination of care between the lung transplant team, the cystic fibrosis care center, and specialists in other disciplines with experience in the care of CF and lung transplant recipients. These consensus statements will help lung transplant providers care for CFLTRs in order to improve post-transplant outcomes in this population.
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We prospectively recruited 23 pediatric lung transplant recipients and 98 pediatric patients with respiratory symptoms undergoing combined endoscopy and bronchoscopy. Gastric, oropharyngeal, and bronchoalveolar lavage samples were collected for 16S sequencing. Gastric samples were also analyzed for bile composition using liquid chromatography.
Patients who underwent lung transplantation had significantly reduced alpha diversity in gastric and oropharyngeal sites compared with patients with respiratory symptoms. This reduction in alpha diversity was especially evident in gastric samples in patients with delayed gastric emptying defined as abnormal gastric emptying on nuclear scintigraphy or as an elevation in gastric bile concentration (p ≤ 0.05). Whereas monocolonies were seen in the lungs of patients who underwent transplantation, these were not the same microbes seen in the stomach; the microbial overlap between lung and gastric samples within patients was low, and data indicated high individual variation between lung transplant recipients. Other contributors to reduced alpha diversity included antibiotics in combination with proton pump inhibitors, especially in gastric and oropharyngeal samples.
Lung transplant recipients have reduced microbial diversity in gastric fluid (GF) and oropharynx compared with patients who did not undergo lung transplantation. The decreased alpha diversity in GF may be associated with dysmotility.
Commentary: Gastroesophageal reflux and lung allograft dysfunction: Need to improve detection and clinical reporting
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Clinical lung and heart/lung transplantationDelayed Gastric Emptying Scintigraphy in Cystic Fibrosis Patients Before and After Lung Transplantation

Background

Methods

Results

Conclusions

Section snippets

Cystic Fibrosis Patients

Results

Discussion

Gastroenterology

J Pediatr

Chest

Chest

Chest

Gastroenterology

J Gastrointest Surg

Gastrointestinal complications in heart and in heart–lung transplant patients

J Heart Lung Transplant

Gastric scintigraphy with a liquid–solid radiolabelled meal: performances of solid and liquid parameters

Nucl Med Commun

Ultrasound measurement of gastric emptying in patients with cystic fibrosis and effect of ranitidine on delayed gastric emptying

J Pediatr

The effect of cimetidine on meal-stimulated gastric function and exogenous pancreatic enzymes in cystic fibrosis

Hum Nutr Clin Nutr

Gastric emptying in infants with cystic fibrosis

Acta Paediatr Scand

Clinical lung and heart/lung transplantation
Delayed Gastric Emptying Scintigraphy in Cystic Fibrosis Patients Before and After Lung Transplantation