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Friday, September 22, 2017

The Brain in Your Gut

I know a lot of people with gastroparesis have memory issues, myself included. So, what causes this? How does our brain chemistry change when you have gastroparesis? Sleep deprivation, malnutrition, and medication can play a big part in altering our brain chemistry but I wanted to dig a bit deeper to see what else can change our body's brain chemistry, and why it affects us so harshly.



Credit: ISTOCKPHOTO/ERAXION


According to Cal Tech http://www.caltech.edu/news/microbes-help-produce-serotonin-gut-46495,

"Although serotonin is well known as a brain neurotransmitter, it is estimated that 90 percent of the body's serotonin is made in the digestive tract. In fact, altered levels of this peripheral serotonin have been linked to diseases such as irritable bowel syndrome, cardiovascular disease, and osteoporosis.

'More and more studies are showing that mice or other model organisms with changes in their gut microbes exhibit altered behaviors,' explains Elaine Hsiao, research assistant professor of biology and biological engineering and senior author of the study. 'We are interested in how microbes communicate with the nervous system. To start, we explored the idea that normal gut microbes could influence levels of neurotransmitters in their hosts.'

Peripheral serotonin is produced in the digestive tract by enterochromaffin (EC) cells and also by particular types of immune cells and neurons. Hsiao and her colleagues first wanted to know if gut microbes have any effect on serotonin production in the gut and, if so, in which types of cells. They began by measuring peripheral serotonin levels in mice with normal populations of gut bacteria and also in germ-free mice that lack these resident microbes.

The researchers found that the EC cells from germ-free mice produced approximately 60 percent less serotonin than did their peers with conventional bacterial colonies. When these germ-free mice were recolonized with normal gut microbes, the serotonin levels went back up—showing that the deficit in serotonin can be reversed.

'EC cells are rich sources of serotonin in the gut. What we saw in this experiment is that they appear to depend on microbes to make serotonin—or at least a large portion of it,' says Jessica Yano, first author on the paper and a research technician working with Hsiao.

The researchers next wanted to find out whether specific species of bacteria, out of the diverse pool of microbes that inhabit the gut, are interacting with EC cells to make serotonin.

After testing several different single species and groups of known gut microbes, Yano, Hsiao, and colleagues observed that one condition—the presence of a group of approximately 20 species of spore-forming bacteria—elevated serotonin levels in germ-free mice. The mice treated with this group also showed an increase in gastrointestinal motility compared to their germ-free counterparts, and changes in the activation of blood platelets, which are known to use serotonin to promote clotting.

Wanting to home in on mechanisms that could be involved in this interesting collaboration between microbe and host, the researchers began looking for molecules that might be key. They identified several particular metabolites—products of the microbes' metabolism—that were regulated by spore-forming bacteria and that elevated serotonin from EC cells in culture. Furthermore, increasing these metabolites in germ-free mice increased their serotonin levels.

Previous work in the field indicated that some bacteria can make serotonin all by themselves. However, this new study suggests that much of the body's serotonin relies on particular bacteria that interact with the host to produce serotonin, says Yano. 'Our work demonstrates that microbes normally present in the gut stimulate host intestinal cells to produce serotonin,' she explains.

'While the connections between the microbiome and the immune and metabolic systems are well appreciated, research into the role gut microbes play in shaping the nervous system is an exciting frontier in the biological sciences,' says Sarkis K. Mazmanian, Luis B. and Nelly Soux Professor of Microbiology and a coauthor on the study. 'This work elegantly extends previous seminal research from Caltech in this emerging field'.

Additional coauthor Rustem Ismagilov, the Ethel Wilson Bowles and Robert Bowles Professor of Chemistry and Chemical Engineering, adds, 'This work illustrates both the richness of chemical interactions between the hosts and their microbial communities, and Dr. Hsiao's scientific breadth and acumen in leading this work.'

Serotonin is important for many aspects of human health
, but Hsiao cautions that much more research is needed before any of these findings can be translated to the clinic.

'We identified a group of bacteria that, aside from increasing serotonin, likely has other effects yet to be explored,' she says. 'Also, there are conditions where an excess of peripheral serotonin appears to be detrimental.'

Although this study was limited to serotonin in the gut, Hsiao and her team are now investigating how this mechanism might also be important for the developing brain. 'Serotonin is an important neurotransmitter and hormone that is involved in a variety of biological processes. The finding that gut microbes modulate serotonin levels raises the interesting prospect of using them to drive changes in biology,' says Hsiao.

The work was published in an article titled 'Indigenous Bacteria from the Gut Microbiota Regulate Host Serotonin Biosynthesis.' In addition to Hsiao, Yano, Mazmanian, and Ismagilov, other Caltech coauthors include undergraduates Kristie Yu, Gauri Shastri, and Phoebe Ann; graduate student Gregory Donaldson; postdoctoral scholar Liang Ma. Additional coauthor Cathryn Nagler is from the University of Chicago."




Image Credit: http://i2.wp.com/sitn.hms.harvard.edu/wp-content/uploads/2016/08/Gut-Brain-Microbe-Figures_FINAL.png





This is an interesting study considering that Gastroparesis/DTP is slow to little to no motility, depending on how severe it is in each person affected with it. If 90 percent of serotonin is produced in the stomach, what happens to that serotonin when the motility is limited or the stomach is removed? Could that be a link to depression in people with Gastroparesis? Scientific American believes that psychiatry may have to readjust to consider just that in the years to come as discussed below.



According to Scientific American https://www.scientificamerican.com/article/gut-second-brain/,

"As Olympians go for the gold in Vancouver, even the steeliest are likely to experience that familiar feeling of 'butterflies' in the stomach. Underlying this sensation is an often-overlooked network of neurons lining our guts that is so extensive some scientists have nicknamed it our 'second brain'.

A deeper understanding of this mass of neural tissue, filled with important neurotransmitters, is revealing that it does much more than merely handle digestion or inflict the occasional nervous pang. The little brain in our innards, in connection with the big one in our skulls, partly determines our mental state and plays key roles in certain diseases throughout the body.

Although its influence is far-reaching, the second brain is not the seat of any conscious thoughts or decision-making.

'The second brain doesn't help with the great thought processes…religion, philosophy and poetry is left to the brain in the head,' says Michael Gershon, chairman of the Department of Anatomy and Cell Biology at New York–Presbyterian Hospital/Columbia University Medical Center, an expert in the nascent field of neurogastroenterology and author of the 1998 book The Second Brain (HarperCollins).

Technically known as the enteric nervous system, the second brain consists of sheaths of neurons embedded in the walls of the long tube of our gut, or alimentary canal, which measures about nine meters end to end from the esophagus to the anus. The second brain contains some 100 million neurons, more than in either the spinal cord or the peripheral nervous system, Gershon says.

This multitude of neurons in the enteric nervous system enables us to 'feel' the inner world of our gut and its contents. Much of this neural firepower comes to bear in the elaborate daily grind of digestion. Breaking down food, absorbing nutrients, and expelling of waste requires chemical processing, mechanical mixing and rhythmic muscle contractions that move everything on down the line.

Thus equipped with its own reflexes and senses, the second brain can control gut behavior independently of the brain, Gershon says. We likely evolved this intricate web of nerves to perform digestion and excretion 'on site,' rather than remotely from our brains through the middleman of the spinal cord. 'The brain in the head doesn't need to get its hands dirty with the messy business of digestion, which is delegated to the brain in the gut,' Gershon says. He and other researchers explain, however, that the second brain's complexity likely cannot be interpreted through this process alone.

'The system is way too complicated to have evolved only to make sure things move out of your colon,' says Emeran Mayer, professor of physiology, psychiatry and biobehavioral sciences at the David Geffen School of Medicine at the University of California, Los Angeles (U.C.L.A.). For example, scientists were shocked to learn that about 90 percent of the fibers in the primary visceral nerve, the vagus, carry information from the gut to the brain and not the other way around. "Some of that info is decidedly unpleasant," Gershon says.

The second brain informs our state of mind in other more obscure ways, as well. 'A big part of our emotions are probably influenced by the nerves in our gut,' Mayer says. Butterflies in the stomach—signaling in the gut as part of our physiological stress response, Gershon says—is but one example. Although gastrointestinal (GI) turmoil can sour one's moods, everyday emotional well-being may rely on messages from the brain below to the brain above. For example, electrical stimulation of the vagus nerve—a useful treatment for depression—may mimic these signals, Gershon says.

Given the two brains' commonalities, other depression treatments that target the mind can unintentionally impact the gut. The enteric nervous system uses more than 30 neurotransmitters, just like the brain, and in fact 95 percent of the body's serotonin is found in the bowels. Because antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) increase serotonin levels, it's little wonder that meds meant to cause chemical changes in the mind often provoke GI issues as a side effect. Irritable bowel syndrome—which afflicts more than two million Americans—also arises in part from too much serotonin in our entrails, and could perhaps be regarded as a "mental illness" of the second brain.

Scientists are learning that the serotonin made by the enteric nervous system might also play a role in more surprising diseases: In a new Nature Medicine study published online February 7, a drug that inhibited the release of serotonin from the gut counteracted the bone-deteriorating disease osteoporosis in postmenopausal rodents. (Scientific American is part of Nature Publishing Group.) 'It was totally unexpected that the gut would regulate bone mass to the extent that one could use this regulation to cure—at least in rodents—osteoporosis,' says Gerard Karsenty, lead author of the study and chair of the Department of Genetics and Development at Columbia University Medical Center.

Serotonin seeping from the second brain might even play some part in autism, the developmental disorder often first noticed in early childhood. Gershon has discovered that the same genes involved in synapse formation between neurons in the brain are involved in the alimentary synapse formation. 'If these genes are affected in autism,' he says, 'it could explain why so many kids with autism have GI motor abnormalities' in addition to elevated levels of gut-produced serotonin in their blood.

Down the road, the blossoming field of neurogastroenterology will likely offer some new insight into the workings of the second brain—and its impact on the body and mind. 'We have never systematically looked at [the enteric nervous system] in relating lesions in it to diseases like they have for the' central nervous system, Gershon says. One day, perhaps there will be well-known connections between diseases and lesions in the gut's nervous system as some in the brain and spinal cord today indicate multiple sclerosis.

Cutting-edge research is currently investigating how the second brain mediates the body's immune response; after all, at least 70 percent of our immune system is aimed at the gut to expel and kill foreign invaders.

U.C.L.A.'s Mayer is doing work on how the trillions of bacteria in the gut 'communicate' with enteric nervous system cells (which they greatly outnumber). His work with the gut's nervous system has led him to think that in coming years psychiatry will need to expand to treat the second brain in addition to the one atop the shoulders."




Image Credit: http://fitlife.tv/wp-content/uploads/2015/06/Gut-System.bmp






According to John's Hopkins http://www.hopkinsmedicine.org/health/healthy_aging/healthy_body/the-brain-gut-connection,

"If you’ve ever "gone with your gut' to make a decision or felt 'butterflies in your stomach' when nervous, you’re likely getting signals from an unexpected source: your second brain. Hidden in the walls of the digestive system, this 'brain in your gut' is revolutionizing medicine’s understanding of the links between digestion, mood, health and even the way you think.

Scientists call this little brain the enteric nervous system (ENS). And it’s not so little. The ENS is two thin layers of more than 100 million nerve cells lining your gastrointestinal tract from esophagus to rectum.



What Does Your Gut’s Brain Control?

Unlike the big brain in your skull, the ENS can’t balance your checkbook or compose a love note. 'Its main role is controlling digestion, from swallowing to the release of enzymes that break down food to the control of blood flow that helps with nutrient absorption to elimination,' explains Jay Pasricha, M.D., director of the Johns Hopkins Center for Neurogastroenterology, whose research on the enteric nervous system has garnered international attention. 'The enteric nervous system doesn’t seem capable of thought as we know it, but it communicates back and forth with our big brain—with profound results.'

The ENS may trigger big emotional shifts experienced by people coping with irritable bowel syndrome (IBS) and functional bowel problems such as constipation, diarrhea, bloating, pain and stomach upset. 'For decades, researchers and doctors thought that anxiety and depression contributed to these problems. But our studies and others show that it may also be the other way around,' Pasricha says. Researchers are finding evidence that irritation in the gastrointestinal system may send signals to the central nervous system (CNS) that trigger mood changes.

'These new findings may explain why a higher-than-normal percentage of people with IBS and functional bowel problems develop depression and anxiety,' Pasricha says. 'That’s important, because up to 30 to 40 percent of the population has functional bowel problems at some point.'



New Gut Understanding Equals New Treatment Opportunities

This new understanding of the ENS-CNS connection helps explain the effectiveness of IBS and bowel-disorder treatments such as antidepressants and mind-body therapies like cognitive behavioral therapy (CBT) and medical hypnotherapy. 'Our two brains ‘talk’ to each other, so therapies that help one may help the other,' Pasricha says. 'In a way, gastroenterologists (doctors who specialize in digestive conditions) are like counselors looking for ways to soothe the second brain.'

Gastroenterologists may prescribe certain antidepressants for IBS, for example—not because they think the problem is all in a patient’s head, but because these medications calm symptoms in some cases by acting on nerve cells in the gut, Pasricha explains. 'Psychological interventions like CBT may also help to 'improve communications' between the big brain and the brain in our gut,' he says.



Still More to Learn About Mind-Gut Link

Pasricha says research suggests that digestive-system activity may affect cognition (thinking skills and memory), too. 'This is an area that needs more research, something we hope to do here at Johns Hopkins,' he says.

Another area of interest: Discovering how signals from the digestive system affect metabolism, raising or reducing risk for health conditions like type 2 diabetes. 'This involves interactions between nerve signals, gut hormones and microbiota—the bacteria that live in the digestive system,'Pasricha says."



Image Credit: https://www.lotronex.com/Images/Patient-MOA_1.jpg


So, the brain in your gut can affect your memory. It makes me think that if you have little or no motility, it could contribute to memory loss, in addition to other things like sleep deprivation, malnutrition, and medication. It seems like a lot of issues can cause memory loss in those who suffer from Gastroparesis/DTP. Personally, I have to carry around a journal to write things in because I forget a lot of things. More research is going into this, so hopefully, we will have answers soon.

Treatment Options for Gastroparesis & Traveling with a Feeding Tube

Treatment Options for Gastroparesis

"Thomas L. Abell, MD

Dr. Abell will share his 35 years of experience with gastroparesis patients, and the perspective gained from 100 patient focus groups. He will discuss the published work on the NIH Gastroparesis consortium, as well as current thoughts on the pathophysiology of gastroparesis and the gastroparesis like syndrome. He will conclude his presentation with a review of therapeutic options for these disorders."


Treatment Options for Gastroparesis: Image and Information Credit: http://oley.org/?page=webinars


For the complete recorded webinar: https://www.youtube.com/watch?v=mcTb-Qzvaak&feature=youtu.be




Traveling with a Feeding Tube

According to the Feeding Tube Awareness Foundation, which can be found here: http://www.feedingtubeawareness.org/navigating-life/on-the-go/traveling/,

"Traveling these days is always a challenge, especially if you will be taking a plane or even a train. But it can be done, with a little preplanning. Here are 5 simple steps to making your trip work.

Talk to your doctor. At least a month prior to travel, talk to your doctor about your travel plans. Ask your doctor to write a letter that explains your child’s medical condition. Make sure it includes a complete list of medical equipment or supplies your child will have while traveling. Print it out, as only paper documentation will get you through security. See this sample letter from the Oley Foundation.

Create an emergency plan. You need to have a plan in place in case something happens. Research where the closest children’s hospital is to your destination. Ask your doctor for a recommendation for a hospital or doctor in case something happens. Also, make sure to plan for any possible emergencies, such as a tube that falls out, a broken pump, or a lost shipment of formula. Consider bringing your child’s medical records, or at least a summary of them, such as a copy of the AAP/ACEP Emergency Information Form for Children With Special Health Care Needs.

Talk to your homecare company. You will need to bring along medical supplies and formula, which can get quite heavy. Ask your homecare company if formula and supplies can be shipped to your destination, or if they have a local branch that can deliver supplies. Make sure you know who to contact if there is a problem with your pump or charger during the trip. In some cases, the homecare company may even provide an extra backup pump for travel.

Determine what you need to pack. More on this below.

Contact the airline, train, or transportation authority at least 72 hours in advance.



What to Pack

This is a general list of things you might need or want to pack for a trip with a child who has a feeding tube. For more detailed information, see the blog Traveling with a Tubie: What to Pack.

Feeding pump and backpack
Feeding sets (bags)
Feeding pump charger
Feeding syringes or gravity bags
Extension sets and adaptors
Syringes for flushing
Venting supplies, such as syringes, Farrell bags, or venting tubes
Water for flushing while traveling — consider bringing 60ml sterile water containers for air travel or travel abroad
Formula, breastmilk, or blenderized meals — with ice packs if necessary
All medications
Small syringes, pill crushers, or medicine cups for medications
A tube replacement kit, including at least one extra tube, lubricant, a syringe for the balloon port if applicable, and tape
Tape, gauze, and dressings as needed


Remember your Charger!


The number one forgotten item when traveling is the feeding pump charger or power cord. Always double check to make sure you have packed yours.

Parent tip: consider bringing a small cooler or insulated lunch bag to transport formula and medications with an ice pack. You can also purchase small refrigerators that plug into your car.



Airline and Train Regulations

It is critical to contact the airline, TSA, or Amtrak in advance if you will traveling with medical supplies. There are many regulations about what can be carried on, what can be checked, and what must be shipped.

For air travel, a good place to start is the TSA Cares hotline at 1-855-787-2227 or TSA-ContactCenter@dhs.gov. The following TSA-related links will help you find general information for traveling with medical supplies.



TSA Tips for Traveling with Medication

Screening for Passengers Requiring Special Assistance
Travelers with Disabilities and Medical Conditions
Screening for Passengers Requiring Special Assistance
3-1-1 Liquids Rule
Traveling with Formula, Breast Milk, and Juice
Disability Notification Card
Traveling with Children
Screening for Passengers Who Require Medically Necessary Liquids
Screening for Passengers with Medical Devices
For train travel, see Amtrak’s Screening Process.



Traveling with Medical Liquids

From time to time, headlines in the news highlight stories of people who run into trouble while traveling with medical supplies and liquids. These stories can be scary for anyone who is considering flying with these items, but don’t let your fear of the TSA screening process stop you from traveling. While there are no guarantees that everything will go perfectly, ample preparation ahead of time will greatly reduce your risk of difficulty with the screening process. Here are a few things to keep in mind when preparing to travel.

1. You can and SHOULD call the TSA Cares hotline before your trip. The purpose of TSA Cares is “to assist travelers with disabilities and medical conditions.” According to the TSA’s website, it is recommended that passengers call the hotline 72 hours prior to traveling. Representatives at TSA Cares are able to give advice specific to each individual’s particular needs that will aid in the security screening process, and give the traveler a better idea of what to expect when they arrive at the security checkpoint. Moreover, the TSA Cares program can provide a TSA agent to escort the traveler through the airport and assist in the screening process. The hotline’s toll-free number is 1-855-787-2227 and the email address is TSA-ContactCenter@dhs.gov. The hotline’s hours of operation are Monday-Friday from 8am-11pm EST and weekends and holidays from 9am-8pm EST.

2. Use the TSA’s Disability Notification Card. This card can be printed from this link and handed to a TSA agent upon arriving at the security checkpoint to make screeners aware that you will need some type of additional consideration during the screening process. The card will not get you out of any part of the screening process, but it will discreetly alert them to your needs and hopefully help the process to go more smoothly.

3. You CAN carry more medical liquids through security than would be allowed through the 3-1-1 rule. Medical liquids such as formula, breast milk, baby food, and liquid medications are allowed through security checkpoints. The TSA website warns, however, that travelers carrying medical liquids MUST declare medical liquids at the beginning of the screening process due to the additional screening measures required. If you or your child require a specialized ready-to-feed formula that cannot be purchased at a retail store in the event that checked baggage were to get lost, it is a good idea to carry enough formula on board for 2 days. That would hopefully allow enough time once you’ve reached your destination to make emergency arrangements with your supply company or find someone local to the area you are visiting that could spare enough extra to hold you over until your baggage arrives. Any necessary medications should ALWAYS be brought in carry-on luggage.

4. For longer trips, ship supplies and formula to your destination ahead of time if possible. This will prevent you from having to pack all of your needed supplies in your checked luggage.

5. Check with your airline about waived baggage fees for medical supplies. Most airlines that charge fees for checked baggage will allow one bag of medical supplies to be checked without paying the usual baggage fee. You may still want to pack one or two days’ worth of supplies in a separate checked bag as well, just in case the medical supply bag arrives late.

6. Pack your liquids last. If they are the last thing you put in your carry-on bag, they will be easily accessible when it’s time to go through security. Put everything in zippered plastic bags so that when you get to the security checkpoint, it will be easy to pull them out without having to dig through your whole carry-on bag.

7. Print all of the TSA policies that pertain to what you’re carrying with you. While the TSA works to ensure proper training for all its agents, there is always a chance that you will encounter an agent who does not have experience with or a thorough understanding of the policies pertaining to medical liquids and supplies. Print any policies from their website that may apply to your situation and keep them in a zippered plastic bag inside the same bag with your medical liquids where they are easily accessible. If anything comes into question, you can quickly identify the policy that pertains to that item. It is also not a bad idea to have a letter from a physician listing the medical liquids, supplies and equipment that you will be traveling with that may affect the security screening process.

8. Don’t send your liquids through the x-ray machine in a closed carry-on bag. If you have your cans or bottles of liquid formula and medications in zippered plastic bags, it’s easy to pull them out and put them in one of the plastic tubs provided at security. (The plastic bag will also keep them from getting dirty since people put their shoes in those tubs, too.) If you have a soft cooler with medical liquids and ice packs in it, unzip and open it before putting it through the x-ray machine and set it into one of the provided plastic tubs. Before any of your medical liquids go through the x-ray machine, make sure that the TSA agents who are doing the x-ray screening see what you have and hear you say that you are sending medical liquids through the machine so they know what’s coming before it pops up on their viewing screen. Most other medical supplies, such as syringes, pump bags, extension tubes, and medical tape can go through the x-ray machine.

9. It’s okay to ask your TSA screener to put on a clean pair of gloves before handling your medical supplies. Ask nicely, and insist if you need to. Explain that because of the individual’s medical conditions, you are doing everything you can to avoid contact with germs and cross-contamination. It may be a good idea to remind them to put on fresh gloves after coming into contact with your medications as well.

10. When you travel with medical liquids, you WILL be asked to open them, or they may be opened for you. The TSA’s website states, “Liquids, gels, and aerosols are screened by X-ray and medically necessary items in excess of 3.4 ounces will receive additional screening. A passenger could be asked to open the liquid or gel for additional screening. TSA will not touch the liquid or gel during this process. If the passenger does not want a liquid, gel, or aerosol X-rayed or opened for additional screening, he or she should inform the officer before screening begins. Additional screening of the passenger and his or her property may be required, which may include a patdown.” If you are carrying ready-to-feed liquid formula in cans or tetra paks, know ahead of time that you will most likely have to open them and bring something to pour the formula into, such as a spare feeding pump bag or empty baby bottles with tight-fitting lids. Even an empty plastic water bottle will do. To avoid concerns over opened formula spoiling, travel with a small soft cooler and ice packs. Opened formula is good for 24 hours when it is kept refrigerated. Medications will need to be opened and tested as well. Even though the TSA doesn’t require it, it’s a very good idea to put bottles of liquid medications in zippered plastic bags in case of spills. It’s also a good idea to make sure the lids are on tight after they’ve been tested and before you put them back in your carry-on.

11. Frozen items do not count as liquids as long as they are frozen solid. The TSA website states that “Frozen items are permitted as long as they are solid and in a ‘frozen state’ when presented for screening.” This includes ice packs used to keep formula and medications cold. However, if they are at all thawed or slushy, they will be subject to the rules and regulations for liquids. For individuals who use a blenderized diet or breast milk for tube feeds, this would also mean that pre-blended formula or breast milk that has been frozen solid would be permitted without being subject to the additional screening for liquids as long as it is not partially thawed.

12. Allow extra time in case you run into delays at security. Of course this is advised for all travelers, but going through the security screening process with larger-than-usual quantities of medical liquids and individuals with special needs means can take extra time. Find out the recommended arrival time for the airport you will be departing from and add an extra half hour or hour to it, just in case. You may end up sitting at the gate for a longer time than you’d like, but that is much better than missing your flight. If you have allowed ample time before your flight, you will not have the added stress during the security screening process of wondering if you’ll miss your flight or not.

13. Be polite. Patience and a positive attitude can go a long way in helping the screening process go smoothly."




Traveling with IV Nutrition or Tube Feeding
Barbara Klinger (experienced traveler with IV nutrition)
Rick Davis (experienced traveler with tube feeding)
Susan Buckland, TSA (Oley Foundation)



Image and Information Credit: http://oley.org/?page=webinars


For the complete recorded Webinar: https://www.youtube.com/watch?v=3UrnyhaA-8Y&feature=youtu.be


Saturday, August 26, 2017

Spreading Positivity in the GP Community: Healing the Rift

I have touched on this before but I thought it was worth repeating. There are a lot of diverse groups that make up the gastroparesis community on social media. There are so many different variety of groups, so that you can usually find a support group that works for you and your needs. This is a very positive thing because gastroparesis can be very isolating. There are times where I feel like I am on house arrest. For instance, it is really hard for me to go places and do things with my friends/family because I vomit so frequently. Some of my friends will start vomiting if they see me do it, so that does not really work out. There are SO many positives to gastroparesis groups:

1. People know where you are coming from
2. People believe you so you do not have to constantly defend yourself
3. You get the support you need from a group set going through the same things
4. You can ask and answer questions
5. You make new friends
6. You get involved with the gastroparesis community
7. You do not have to censor yourself, because there is no such thing as TMI (too much information) in a support group
8. You can join multiple groups (it is better to do this since groups have specialities or if you want different perspectives)
9. It is nice to connect with others, especially if you are alone
10. You have the ability to help the newly diagnosed and share your experiences with them


Those are the positives that I love seeing in groups. The gastroparesis groups can be welcoming and inviting but you might have to search around until you can find one that is the fit for you. Usually, people in groups are willing to give suggestions to direct you to other groups if you feel like the one you joined is not the fit for you.


I have a list of gastroparesis resources here: HERE.


Now, I want to address something else, the negative sides of gastroparesis groups and by extension, the community. There seems to be a huge rift in our gastroparesis community at the moment and it seems to focus on each of the gastroparesis groups doing their own things. It does NOT matter how the rift in the groups began, who is at fault, because ultimately, we are hurting our main goal - which is gastroparesis awareness, and most importantly, each other.

Our community needs to heal and come together to work together to try and fight doctors, nurses, and others who think that gastroparesis is NOT real, despite test results that tell the contrary. It is a waste of our energy to fight one another when we should all be working towards a common goal. Instead, we are shooting ourselves in the foot and before long, no one is going to take us seriously. With all of this squabbling and fighting amongst each other, we are losing sight of the real message: to spread awareness about our illness. It's not a competition and we do have a common goal.

Therefore, this needs to end.

We are better than this. We need to work on making sure people know what gastroparesis is, how it effects so many, their quality of life, and to fight for those who barely have the energy to fight for themselves. We also need to dispense with the blame game. This fracturing is devastating to our community. Furthermore, even people in other support groups, like the cancer and stroke groups, are inquiring as to what is going on with the gastroparesis community. This has gotten out of hand and needs to stop. We cannot take the community out of gastroparesis community.


You do not have to like someone, but you CAN respect them.


All of the cliques, the in fighting, back biting, passive aggression - ALL OF IT, in groups needs to end. That is NOT what support is. It is hurting our cause instead of helping it. All of us have worked hard to get the community where it is today. It's taken a lot of work from so many people, and it is a very thankless job which we do for free in our spare time. We all do it because we love this community but also because it is important for us to find better treatment plans, and hopefully, a cure. We have lost THIRTY-FOUR people in the past two to three months. Let that sink in for a minute. We should honor those fallen warriors by continuing to promote awareness for gastroparesis.


No awareness, no research, no cure.


This giant rift in the gastroparesis community needs to close. No one needs to take sides. Instead, take the side of gastroparesis, and fight with everything you have to spread awareness, spread joy to those who are feeling down, spread friendship to those with this illness who are isolated. There are so many positives we could be doing! The gastroparesis community needs to come together and help each other out.

I would be happy to promote other groups, pages, etc, just like I have always done. To me, getting the word out matters and politics does not. I just do not understand how this happened in our community. But, I do want to rescue it and work with others before we lose all credibility completely. Like I previously stated, we already have a hard enough time fighting doctors, hospitals, and everything else. We all should look out for one another. We are a strong community, but we need to heal and move forward.




Image taken from: http://www.sanluisobispo.com/living/family/linda-lewis-griffith/article39430086.html





According to Senior Outlook (http://www.sanluisobispo.com/living/family/linda-lewis-griffith/article39430086.html,

"Even good relationships can be damaged by an argument, jealousy, misunderstanding, insult, rumor, or buildup of small resentments.

Sometimes things blow over quickly, but other times the upset lasts for years or even indefinitely. As time passes, people may even forget why they originally became upset.

Meanwhile, discord eats away at the peace of mind of those involved, and that affects the body. Negative emotions can release adrenaline and cortisol, chemicals useful in short-term fight-or-flight responses but destructive to the immune system when circulated in the bloodstream for extended periods. Augustine of Hippo (St. Augustine, 354–430 A.D.) wrote, 'Resentment is like taking poison and hoping the other person dies.'

Further bodily damage can be wrought. Many believe the mind delivers to your body whatever you speak, think, or otherwise focus on. If true, what bodily symptoms might result from expressing such thoughts as 'He’s a real pain in the neck/butt,' 'She makes me sick,' or 'I’m so sick and tired of that guy?'

Friends surrounding this ailing relationship are affected, too. After a friendship breaks up, party hosts may rightly invite both feuding friends; but then they may be asked awkward questions regarding whether the other person plans to attend. If both individuals attend anyhow, they may avoid or confront one other, making others uncomfortable.

What about innocent bystanders within the family—parents, children, siblings, and grandparents? Some family members feel forced to choose sides if two of their children or siblings aren’t speaking to each other. And how do you manage family holidays together? A schism within the family destroys peace.

All these unpleasant side effects are ample incentive to try to mend the torn relationship and restore peace and harmony between the two of you and among those dear to you both.

Writing a reconciliation letter is a good first step. Deliver your truth with compassion. Start with a sincere compliment or other positive statements; then create an emotional connection by mentioning what you’ve always enjoyed about each other or what you once enjoyed doing together—times you both treasured.

Acknowledge that no two people ever perceive or recall a situation in exactly the same way. Truthfully but kindly describe the situation—as you recall it—that you believe has caused the current upset. Avoid starting sentences with 'You,' such as 'You said,' as these statements seem accusatory. Instead, describe your own feelings in response to circumstances at the heart of the upset, e.g., 'I was devastated when I heard that statement made in front of everyone at the party.'

Accept responsibility and apologize for any part you may have played in the upset. Then ask for and/or extend forgiveness—whatever is appropriate. End by expressing hope of reconciliation, or at least an agreement to 'live and let live,' for personal peace as well as harmony among affected family and friends.

To allow the other person a chance to offer a considered response, not an emotionally charged one, mail your letter. Don’t ask for signed proof of delivery; this could be interpreted as a pressure tactic or power play. Just write 'Personal & Confidential—Please Deliver Unopened' to the right of your return address to help ensure privacy.

If you receive no response within a month, send a brief note stating you hope the note finds him or her well, you care about your relationship, and you’re hoping to hear from him or her regarding the letter you sent on (date). Consider attaching a duplicate of the letter, just in case.

With that, you’ll know you’ve made your best peacemaking effort; accept the outcome. Forgive yourself, if you haven’t already, for anything you might have contributed to the upset, because this, too, is healing. Finally, should you find yourself face to face with the other person, behave as if the upset never happened in the first place. This makes it easy, if the other person so desires, to gracefully resume that good relationship, without embarrassment or any need to explain.

And if, in the future, any resentment toward the other person creeps back into your thoughts, immediately forgive him or her mentally, and then once again forgive yourself. Repeat as often as needed."


The community needs to band together once more and fight for one another, not fight each other.

Hirschsprung's Disease

One of my friends was recently diagnosed with this disease, and I have to admit that I had no clue about it. I knew about little to no colon motility, but I never knew that this had a name. There are lots of things that can slow the colon or stop it working completely, like scleroderma, Ehler Danlos Syndrome, and Gastroparesis. I wanted to do some research on Hirschsprung's Disease to see what information I could find to help others who may be suffering from the same thing.


According to the Atlas of Pathophysiology (http://doctorlib.info/physiology/pathophysiology/79.html),

"Hirschsprung's disease, also called congenital megacolon or congenital aganglionic megacolon, is a congenital disorder of the large intestine, characterized by absence or marked reduction of parasympathetic ganglion cells in the colorectal wall. Hirschsprung's disease appears to be a familial, congenital defect, occurring in 1 in 5,000 to 1 in 8,000 live births. It's up to 7 times more common in males than in females (although the aganglionic segment is usually shorter in males) and is most prevalent in whites. Total aganglionosis affects both sexes equally. Females with Hirschsprung's disease are at higher risk for having affected children. This disease usually coexists with other congenital anomalies, particularly trisomy 21 and anomalies of the urinary tract such as megaloureter."



Image taken from: http://slideplayer.com/slide/7541905/24/images/1/HIRSCHSPRUNG+S+DISEASE+congenital+megacolon.jpg




According to the Mayo Clinic (http://www.mayoclinic.org/diseases-conditions/hirschsprung's-disease/home/ovc-20214664), the symptoms of Hirschsprung's Disease are included but not limited to,


"Hirschsprung's (HIRSH-sproongz) disease is a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby's colon.

A newborn who has Hirschsprung's disease usually can't have a bowel movement in the days after birth. In mild cases, the condition might not be detected until later in childhood. Uncommonly, Hirschsprung's disease is first diagnosed in adults.

Surgery to bypass or remove the diseased part of the colon is the treatment."



Image taken from: http://www.birth-defect.org/wp-content/uploads/7f5592e639cf5afb772e168b4a153572.jpg



However, even though it is rare or uncommon, adults can very much get it as well.


The symptoms, according to Mayo (http://www.mayoclinic.org/diseases-conditions/hirschsprung's-disease/symptoms-causes/dxc-20214666), are,

"Signs and symptoms of Hirschsprung's disease vary with the severity of the condition. Usually signs and symptoms appear shortly after birth, but sometimes they're not apparent until later in life.

Typically, the most obvious sign is a newborn's failure to have a bowel movement within 48 hours after birth.


Other signs and symptoms in newborns may include:

Swollen belly

Vomiting, including vomiting a green or brown substance

Constipation or gas, which might make a newborn fussy

Diarrhea


In older children/adults, signs and symptoms can include:

Swollen belly

Chronic constipation

Gas

Failure to thrive

Fatigue


It's not clear what causes Hirschsprung's disease. It sometimes occurs in families and might, in some cases, be associated with a genetic mutation.

Hirschsprung's disease occurs when nerve cells in the colon don't form completely. Nerves in the colon control the muscle contractions that move food through the bowels. Without the contractions, stool stays in the large intestine.


Factors that may increase the risk of Hirschsprung's disease include:

Having a sibling who has Hirschsprung's disease. Hirschsprung's disease can be inherited. If you have one child who has the condition, future biological children could be at risk.

Being male. Hirschsprung's disease is more common in males.

Having other inherited conditions. Hirschsprung's disease is associated with certain inherited conditions, such as Down syndrome and other abnormalities present at birth, such as congenital heart disease."




Image taken from: http://www.medindia.net/images/common/patientinfo/950_400/abdominal-x-ray-can-helps-to-diagnose-the-hirschsprung-disease.jpg




According to MedicineNet (http://www.medicinenet.com/hirschsprung_disease/article.htm,

"The cause of Hirschsprung disease is due to nerve cells that are supposed to grow along the intestine and reach the anus, but do not because they stop growing too soon. Hirschsprung disease (HSCR) is a congenital (present at birth) disease of the large intestine or colon. It is one type of birth defect. People with the disease do not have the nerve cells in the intestine required to expel stools from the body normally.

Some people inherit the disease, and others have mutations in several genes. In about 50% of people with Hirschsprung disease, researchers and doctors do not know what genes cause it.

Your primary care doctor will refer you to a specialist in digestive disorders called a gastroenterologist, to diagnose the condition. Diagnosis for Hirschsprung’s is based on a physical exam, medical and family history, symptoms, and tests, for example, a digital exam.
Surgery is the treatment for this life-threatening disease (procedures include pull-through for infants and ostomy (An ostomy refers to the surgically created opening in the body for the discharge of body wastes) for toddles and older children).

After healing from surgery, your child's bowel movements may become normal. But surgery doesn't cure Hirschsprung disease. Some children/adults will have bowel problems – like constipation or fecal incontinence (“accidents”) – off and on throughout their lives.


Symptoms of Hirschsprung disease in toddlers and older children may include:

Not being able to pass stools without enemas or suppositories. An enema involves flushing liquid into the child’s anus using a special wash bottle. A suppository is a pill Placed into the child’s rectum.

Swelling of the abdomen.

Diarrhea, often with blood.

Slow growth.

Intellectual disability"



Image taken from: http://image.slidesharecdn.com/hirschsprungsdisease-140510235224-phpapp01/95/hirschsprungs-disease-3-638.jpg?cb=1399767420




According to Science Direct (http://www.sciencedirect.com/science/article/pii/S2237936315000519,

"Some patients reach adulthood without a diagnosis for this disease. Typically, patients go to the doctor with a long-standing history of constipation requiring frequent laxative use.11 The current frequency of the disease in adults is unknown, especially since HD is an overlooked and misdiagnosed disease in this age group. ...the diagnosis of HD is supported by barium enema studies, anorectal manometry and rectal biopsy.

Imaging studies such as computed tomography (CT) and barium enemas are usually accepted for evaluation of chronic constipation, which is a common disorder in adults. Our patient underwent CT due to the unavailability of a barium enema study, but CT is a more expensive method.

The anorectal manometry, even though not contributing in the present case, is an ancillary test of the utmost importance, since the presence of the rectum-anal reflex in this exam usually rule out the diagnosis of HD.

Several procedures are used to manage this disease after childhood; currently the option of choice is the surgical procedure of Duhamel. Late diagnosis contributes to the need for surgery in more than one surgical time, with ileostomy or colostomy, since the healthy colon is more distended in adolescents and adults compared to neonates and children. Nevertheless, the literature considers as the procedure of choice the Duhamel technique in only one surgical time, which reduces the hospitalization time.

This surgery is considered curative. However, post-operative bowel functioning is not always satisfactory. Enterocolitis, constipation and fecal incontinence represent the main postoperative complications in children. To date, the progression for adolescent or adult patients is not fully clarified yet, due to the small number of reported cases."



Image taken from: https://i.pinimg.com/736x/80/76/5d/80765d68dfe49fd160965c6aa5410100--menu-google-search.jpg



I really hope this will help educate you about Hirschsprung disease. I am still learning about it myself. The research I did says it is more likely to happen with children, but adults I know have it and were just officially diagnosed. After you have a rectal biopsy (because doctors do a biopsy to verify you do have HD), then they might do an anorectal manometry (which is where they stick a balloon up your rectum, kind of like the pelvic floor test). Once all of that has been confirmed, then they might start talking reconstructive pelvic surgery.


I would still advise you to be cautious, do your own research, talk to people who have had it done, and make an informed decision so you will know if this is right for you. Thank you very much to my friend who brought this illness to my attention, because I had no idea this was going on. My heart goes out to all of you who are fighting this on a daily basis.

Thursday, August 3, 2017

Cyber Bullying and the GP Community

There has been a lot of bullying going on within the gastroparesis community, a lot of which has been aimed at me. I keep getting harassed, had former friends harass me, my pages, and my blog. My blog has been the crux of this issue a few times. I want to say that my blog is not a scientific journal, so it is not peer reviewed. It's a blog. I've been told that twice by the same person. I have been published in two geological journals, but I do not think the lead count in soil would help any GPers I know.

GP isn't a social club. It's about working together to get the information out there and to help those who have GP. It is not about ganging up on people, controlling groups, pages, etc. It's about support, pure and simple. There are so many obstacles that we have to go through with gastroparesis, we shouldn't manufacture more, we should stand united. We need to educate those who may not know about gastroparesis and what that entails. It's August - GP Awareness Month. We should rally together to educate, not tear each other down. Divided we fall, united we conquer.

I want to talk about cyber bullying, since I'm experiencing it firsthand, and what it's doing to the gastroparesis community. I also want to help others who may be going through the same things. It's hard being bullied, especially if Facebook won't listen and you don't have any other recourse. I'll share some things I have learned and some tips from an anti-bullying site that I found. We should be building each other up and not tearing each other down. Having gastroparesis is hard enough, and we face enough adversity from doctors, nurses, ER staff, etc, we don't need it from each other.


So, here's what you can do to avoid cyber bullying.

1. Do not feed the troll. What I mean by that is, do not give the person fuel for their fire to keep attacking you. As hard as it is, stay silent. These people crave attention and will try to get it by any means necessary.

2. Block these people. They have no control over your life unless you let them. You are better off without these toxic people in your lives. You ARE important, and don't let these people have control over what you do.

3. Write yourself an email. Every time these people hurt you and you want to say something back, write yourself an email and send it to yourself to get your feelings out. That way, you don't bottle it up and you can get out what you want to say. You don't need to send it to anyone else, this is just for you.

4. Do not be scared. Don't be scared to login to Facebook or wherever these trolls might be lurking. That would be giving them power over you. Don't let them. You're better than that, and like it or not, these people are going to be everywhere so there is really not a way to avoid them.

5. Do not give in. These people want something from you, don't give it to them. Bullies usually won't stop until they can get what they want. I will give an example. This is a popular one - in movies and T.V. shows - bullies want lunch money. They will not stop punching you in the gut until they get it and run off. So, don't give the bullies your "lunch money."

6. Do not stop living your life. The thing with bullies is that they will try to interrupt as much of your life as possible. Do not let them. The world spins on. You should keep living your life and do not let them make you deviate from it, because that is their goal.


I would also check with your state and see what laws they may have in place about cyber bullying.





Source: http://www.demfreshmen.com/wp-content/uploads/2016/07/Dem-FreshMen-Birmingham-Alabama-Zeus-Zyoos-zoos-Entertainment-LLC111.jpg






According to http://cyberbullying.org/advice-for-adult-victims-of-cyberbullying,

"We get a lot of emails, phone calls, and comments on this blog from adults who are being bullied though technology. They stress to us that cyberbullying is not just an adolescent problem. Believe me, we know. We receive more inquiries from adults than teens. We know that cyberbullying negatively affects adults too. It’s just that we spend the majority of our efforts studying how this problem impacts school-aged youth due to their tenuous developmental stage. That said, I thought I would take some time here to give the adults who have been victimized out there some general advice.

First, it is important to keep all evidence of the bullying: messages, posts, comments, etc. If there are ways you can determine who exactly is making the comments, also document that. Second, contact the service or content provider through which the bullying is occurring. For example, if you are being cyberbullied on Facebook, contact them. If you are receiving hurtful or threatening cell phone messages, contact your cell phone company to obtain assistance. Along those same lines, familiarize yourself with the Terms of Use for the various sites you frequent, and the online accounts you sign up for. Many web sites expressly prohibit harassment and if you report it through their established mechanisms, the content and/or bully should be removed from the site in a timely manner. To be sure, some web site administrators are better and quicker at this than others.

Also, please be careful not to retaliate – or do anything that might be perceived by an outsider to have contributed to the problem. Do not respond to the cyberbully except to calmly tell them to stop. If they refuse, you may have to take additional actions. If you are ever afraid for your safety, you need to contact law enforcement to investigate. They can determine whether any threats made are credible. If they are, the police will formally look into it. The evidence that you have collected will help them to evaluate your situation.

You should also take the time to check your state laws. We have discussed some of these laws on this blog and have a summary of many applicable laws here. In Wisconsin, for example, it is a misdemeanor if someone uses computerized communication systems to “frighten, intimidate, threaten, abuse, or harass another person.” It is also against the law to “harass annoy, or offend another person.” See what the laws in your state are to determine if the police should get involved.

If the threats or comments are detrimental to your health, safety, or occupation, you might want to consult with an attorney who specializes in harassment, defamation of character, false light, intentional infliction of emotional distress, or similar types of civil action. A letter sent from an attorney (on law firm letterhead) to the bully may be all that is necessary to get the bullying to stop. The problem with this approach is that it can be costly. I have spoken to some victims who have consulted with attorneys who want a significant sum of money to get involved, even at a basic level. I can only imagine how frustrating this is after experiencing emotional and psychological suffering – and then realizing that you can’t afford to get legal help. Another problem associated with pursuing a bully through civil action is that, even if you are successful and a judge or jury rules in your favor, it can be difficult to determine an appropriate damage amount. I served as an expert witness in a cyberbullying case in the summer of 2008. In that case, the adult victims were being bullied in an AOL chat room. Everyone agreed that what the bully was doing was wrong, but to what were the victims entitled? They had some modest medical bills and could be reimbursed for costs associated with their AOL account – but these losses added up to less than $1,000. And while I don’t know the actual amount, I am sure their legal bills were in the tens of thousands of dollars. They ended up settling for a very small amount – just to make a statement to the bully. Most of us can’t afford to take those actions on principle alone.

In sum, it can be difficult to hold bullies accountable for their actions (for both adolescents and adults). In a country such as ours that values free speech so highly, many people genuinely believe they can say whatever they want, to whomever they want. We know that is not true, but it isn’t clear where exactly the line is. And just because we *can* say certain things, doesn’t mean we should. It’s no wonder that many teens are wrestling with this problem—they see the adults in their lives saying mean and nasty things to others on a regular basis. Do your part to model appropriate behavior and address any hurtful language when it comes up. The kids (and other adults) in your life will hopefully see it, remember it, and act in the right ways."



I know first hand what bullying feels like and it is not the most pleasant feeling. It is so hard to stay silent when people are attacking you left and right. The hardest thing you can do is to keep your peace and not feed into what they want, which is any kind of reaction out of you. Anything you say in your defense will just be used against you later in one form or another, and just give them more fuel for their fire. It is so hard to sit back and watch people defame you, your character, your family, your contributions to the community, or whatever they feel the need to target. It hurts. I know it hurts so much. I have cried over things that were said and done to me.

It hurts so much, and the worst feeling that you feel is powerless. But, you are NOT powerless. You have a lot more power than you know of. By not feeding into this hate, you are breaking the bullying cycle. Be sure to document EVERYTHING! You can keep a file with print outs of what has been said about you, if it was online. If it is through the phone company, save your voicemails. Gather all of the evidence that you can, while you can. You can look up cyber bullying or bullying laws in your state, it varies, but there are legal courses of action that one can take. I would also recommend talking to a therapist to get out all of your feelings regarding the way you are being treated. Your therapist might have some great ideas on how to deal with a bully as well. Just know that you are NOT alone! You do NOT have to go through this alone! You are special, here for a reason, and no one is worth it if all they do is tear you down. You are amazing and in case no one has told you this today, I believe in you.


Source: https://s-media-cache-ak0.pinimg.com/736x/12/d1/70/12d170eead706aec33eccbc2b5c7704c--no-bullying-cyber-bullying.jpg

I wanted to share my favorite poem because it has gotten me through some really rough times and it might help someone else. It comforts me when I'm at my lowest. I had to memorize it in middle school but I still love it to this day. If it will help or reach someone who is going through a tough time, then I'm glad. I recite it to myself when I feel defeated or upset. It's a really great poem.

"If

BY RUDYARD KIPLING

If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don’t deal in lies,
Or being hated, don’t give way to hating,
And yet don’t look too good, nor talk too wise:

If you can dream—and not make dreams your master;
If you can think—and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you’ve spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build ’em up with worn-out tools:

If you can make one heap of all your winnings
And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: ‘Hold on!’

If you can talk with crowds and keep your virtue,
Or walk with Kings—nor lose the common touch,
If neither foes nor loving friends can hurt you,
If all men count with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds’ worth of distance run,
Yours is the Earth and everything that’s in it,
And—which is more—you’ll be a Man, my son!"

Source: http://www.poetryfoundation.org/poems/46473/if---

Saturday, June 10, 2017

The Vagus Nerve Stimulator

The Vagus Nerve Stimulator (VNS) is a medical treatment that involves delivering electrical impulses to the vagus nerve. The Vagus Nerve Stimulator, which is new to me so I wanted to do research on it, definitely would help a variety of conditions like epilepsy, depression, multiple sclerosis, headache, pain and Alzheimer's disease. It would probably even help with gastroparesis as well, though I'd check with your doctor first to be one hundred percent sure. Gastroparesis and DTP are caused by vagus nerve damage. If it sends electric impulses down your vagus nerve, it might help your stomach muscles contract and help with gastric emptying. There isn't enough research about Gastroparesis and the VNS so I cannot give you a definitive answer on whether it would help with Gastroparesis or not. However, I did research on the VNS itself, below, because I am not really familiar with it yet. I hope the research helps and I am going to mention this procedure to my GI to see if he would recommend it or if it can be used for Gastroparesis. It has been approved by the FDA for cluster headaches, which I found interesting reading the articles below.



If you are not familiar with the vagus nerve and how much it controls, please read my other article. The link is below:

http://www.emilysstomach.com/2016/07/information-about-vagus-nerve.html


Source: http://www.epilepsy.org.uk/sites/epilepsy/files/images/advice/vns_cyberonics.jpg



The Mayo Clinic describes the Vagus Nerve Stimulator (VNS) as:

"Vagus nerve stimulation is a procedure that involves implantation of a device that stimulates the vagus nerve with electrical impulses.

There's one vagus nerve on each side of your body, running from your brainstem through your neck to your chest and abdomen.

Vagus nerve stimulation is most often used to treat epilepsy when other treatments haven't worked. Vagus nerve stimulation is also a treatment for hard-to-treat depression that hasn't responded to typical therapies.

Researchers are currently studying vagus nerve stimulation as a potential treatment for a variety of conditions, including multiple sclerosis, headache, pain and Alzheimer's disease.

In conventional vagus nerve stimulation, a device is surgically implanted under the skin on your chest, and a wire is threaded under your skin connecting the device to the left vagus nerve. The right vagus nerve is not used because it carries fibers that supply nerves to the heart.

When activated, the device sends electrical signals along the vagus nerve to your brainstem, which then sends signals to certain areas in your brain.

New, noninvasive vagus nerve stimulation devices, which do not require surgical implantation, have been approved for use in Europe to treat epilepsy, depression and pain but have not yet been approved for use in the U.S. An implantable device that stimulates the right vagus nerve is also under study for the treatment of heart failure.




Before the procedure

Before surgery, your doctor will do a physical examination. You may need blood tests or other tests to make sure you don't have any health concerns that might be a problem.

Your doctor will have you start taking antibiotics before surgery to prevent infection.



During the procedure

Surgery to implant the vagus nerve stimulation device is done either on an outpatient basis, allowing you to go home that same day, or on an inpatient basis, requiring an overnight stay in the hospital.

The surgery usually takes one to two hours. You may remain awake but have medication to numb the surgery area (local anesthesia) or you may be unconscious during the surgery (general anesthesia).

The surgery itself doesn't involve your brain. Two small incisions are made, one on your chest and the other on the left side of the neck.

The pulse generator is implanted in the upper left side of your chest. The device is meant to be a permanent implant, but it can be removed if necessary.

The pulse generator is about the size of a stopwatch and runs on battery power. A lead wire is connected to the pulse generator. The lead wire is guided under your skin from your chest up to your neck, where it's attached to the left vagus nerve through the second incision.



After the procedure

The pulse generator is turned on during a visit to your doctor's office a few weeks after surgery. Then it can be programmed to deliver electrical impulses to the vagus nerve at various durations, frequencies and currents.

Vagus nerve stimulation usually starts at a low level and is gradually increased, depending on your symptoms and side effects.

Stimulation is programmed to turn on and off in specific cycles. You may have some tingling sensations or slight pain in your neck when the nerve stimulation is on.

Usually, the stimulations are set to occur every one to three minutes. Programming is performed at the physician's office using a hand-held programming device.

The stimulator doesn't detect seizure activity or depression symptoms. When it's turned on, the stimulator turns on and off at the intervals selected by your doctor.

You'll be given a hand-held magnet so that you can initiate a stimulation yourself if you or others sense the beginning of a seizure.

The magnet can also be used to temporarily turn off the vagus nerve stimulation, which may be necessary when you do certain activities such as public speaking, singing or exercising, or when you're eating if you have swallowing problems.

You must visit your doctor periodically to make sure that the pulse generator is working correctly and that it hasn't shifted out of position. Most people see their doctor once or twice a year for this purpose.

You should also contact your doctor before you have any medical tests, such as magnetic resonance imaging (MRI), which might interfere with your device, or have another medical device implanted.



Results

Vagus nerve stimulation isn't a cure for epilepsy. Most people with epilepsy won't stop having seizures or taking epilepsy medication altogether after the procedure.

But many will have fewer seizures, up to 20 to 50 percent fewer. Seizure intensity may lessen as well.

It can take as long as 18 months of vagus nerve stimulation before you notice any significant reduction in seizures. Vagus nerve stimulation may also shorten the recovery time after a seizure.

People who've had vagus nerve stimulation to treat epilepsy may also experience improvements in mood and quality of life.

Research is still mixed on the benefits of vagus nerve stimulation for the treatment of depression.

Some studies suggest the benefits of vagus nerve stimulation for depression accrue over time, and it may take several months of treatment before you notice any improvements in your depression symptoms.

In addition, vagus nerve stimulation doesn't work for everybody, and it generally isn't meant to replace traditional treatments.

Additionally, some health insurance carriers may not pay for this procedure.

Studies of vagus nerve stimulation as a treatment for conditions, such as Alzheimer's disease, migraine and multiple sclerosis, have been too small to draw any definitive conclusions about how well it may work for those problems. More research is needed."
Source: http://www.mayoclinic.org/tests-procedures/vagus-nerve-stimulation/home/ovc-20167755



In vagus nerve stimulation, an implanted pulse generator and lead wire stimulate the vagus nerve, which leads to stabilization of abnormal electrical activity in the brain.
Source: http://www.mayoclinic.org/tests-procedures/vagus-nerve-stimulation/multimedia/vagus-nerve-stimulation/img-20006852



According to Wikipedia, it has a lot of different medical uses such as,

"Because the vagus nerve is associated with many different functions and brain regions, research is being done to determine its usefulness in treating other illnesses, including various anxiety disorders, Alzheimer's disease, migraines, fibromyalgia, obesity, and tinnitus.

Alcohol addiction
Atrial fibrillation
Autism
Bulimia nervosa
Burn-induced organ dysfunction
Chronic heart failure
Chronic intractable hiccups
Comorbid personality disorders
Coronary artery disease
Dravet syndrome
Drop-attacks
Heatstroke
Heroin seeking behavior
Intestinal epithelial barrier breakdown
Lennox–Gastaut syndrome
Memory
Mood disorders in elderly population
Multiple sclerosis
Myocarditis
Obsessive compulsive disorder
Peripheral arterial occlusion disease
Postoperative cognitive dysfunction in elderly patients
Rasmussen's encephalitis
Severe mental diseases
Sepsis
Spinal trigeminal neuronal
Transient focal cerebral ischemia
Trauma-hemorrhagic shock
Traumatic brain injury
Vaginal-cervical self-stimulation in women with complete spinal cord injury
Vegetative states after traumatic brain injury
Visceral pain-related affective memory
Other brain stimulation techniques used to treat depression include electroconvulsive therapy (ECT) and cranial electrotherapy stimulation (CES). Deep brain stimulation is currently under study as a treatment for depression. Transcranial magnetic stimulation (TMS) is under study as a therapy for both depression and epilepsy. Trigeminal Nerve Stimulation (TNS) is being researched at UCLA as a treatment for epilepsy."


Unless you have a surgically implanted device you actually cannot directly stimulate your vagus nerve; however, you can indirectly stimulate your vagus nerve to relieve keyed up or shut down nervous system states. Remember, your vagus nerve passes through your belly, diaphragm, lungs, throat, inner ear, and facial muscles. Therefore, practices that change or control the actions of these areas of the body can influence the functioning of the vagus nerve through the mind-body feedback loop.


According to Dr. Arielle Schwartz, you can try these from the comfort of your living room:

"Humming: The vagus nerve passes through by the vocal cords and the inner ear and the vibrations of humming is a free and easy way to influence your nervous system states. Simply pick your favorite tune and you’re ready to go. Or if yoga fits your lifestyle you can “OM” your way to wellbeing. Notice and enjoy the sensations in your chest, throat, and head.

Conscious Breathing: The breath is one of the fastest ways to influence our nervous system states. The aim is to move the belly and diaphragm with the breath and to slow down your breathing. Vagus nerve stimulation occurs when the breath is slowed from our typical 10-14 breaths per minute to 5-7 breaths per minute. You can achieve this by counting the inhalation to 5, hold briefly, and exhale to a count of 10. You can further stimulate the vagus nerve by creating a slight constriction at the back of the throat and creating an “hhh”. Breathe like you are trying to fog a mirror to create the feeling in the throat but inhale and exhale out of the nose sound (in yoga this is called Ujjayi pranayam).

Valsalva Maneuver: This complicated name refers to a process of attempting to exhale against a closed airway. You can do this by keeping your mouth closed and pinching your nose while trying to breathe out. This increases the pressure inside of your chest cavity increasing vagal tone.

Diving Reflex: Considered a first rate vagus nerve stimulation technique, splashing cold water on your face from your lips to your scalp line stimulates the diving reflex. You can also achieve the nervous system cooling effects by placing ice cubes in a ziplock and holding the ice against your face and a brief hold of your breath. The diving reflex slows your heart rate, increases blood flow to your brain, reduces anger and relaxes your body. An additional technique that stimulates the diving reflex is to submerge your tongue in liquid. Drink and hold lukewarm water in your mouth sensing the water with your tongue.

Connection: Reach out for relationship. Healthy connections to others, whether this occurs in person, over the phone, or even via texts or social media in our modern world, can initiate regulation of our body and mind. Relationships can evoke the spirit of playfulness and creativity or can relax us into a trusting bond into another. Perhaps you engage in a lighthearted texting exchange with a friend. If you are in proximity with another you can try relationship expert, David Snarch’s simple, yet powerful exercise called 'hugging until relaxed.' The instructions are to simply 'stand on your own two feet, place your arms around your partner, focus on yourself, and to quiet yourself down, way down.'

Knowing practices for self-care are important. However, it is also important to know how and when to seek out professional therapeutic help. Asking for help can often be the hardest step. You do not need to walk the healing path alone."
Source: http://drarielleschwartz.com/natural-vagus-nerve-stimulation-dr-arielle-schwartz/#.WTxbvRPyvUo




Source: http://s-media-cache-ak0.pinimg.com/originals/fa/0b/55/fa0b55237c346fe50908d402f25b5d5a.jpg




The risks for the VNS, include side effects for the stimulator itself and surgical risks. According to the Mayo Clinic, they are,

"For most people, vagus nerve stimulation is safe. But it does have some risks, both from the surgery to implant the device and from the brain stimulation.


Surgery risks

Surgical complications with vagus nerve stimulation are rare and are similar to the dangers of having other types of surgery. They include:

Pain where the cut (incision) is made to implant the device
Infection
Incision scarring
Difficulty swallowing
Vocal cord paralysis, which is usually temporary, but can be permanent
Side effects after surgery

Some of the side effects and health problems associated with vagus nerve stimulation can include:

Voice changes
Hoarseness
Throat pain
Cough
Headache
Chest pain
Breathing problems, especially during exercise
Difficulty swallowing
Abdominal pain or nausea
Tingling or prickling of the skin
Insomnia
Slowing of the heart rate (bradycardia)
For most people, side effects are tolerable. They may lessen over time, but some side effects may be bothersome for as long as you use vagus nerve stimulation.

Adjusting the electrical impulses can help minimize these effects. If side effects are intolerable, the device can be shut off temporarily or permanently."
Source: http://www.mayoclinic.org/tests-procedures/vagus-nerve-stimulation/details/risks/cmc-20167760
Source: http://www.healthrising.org/wp-content/uploads/2015/05/Vagus-Nerve-Stimulation.jpg


Tuesday, June 6, 2017

Nissen Fundoplication

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.

In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped the entire 360 degrees around the esophagus. In contrast, surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.

The procedure is now routinely performed laparoscopically. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying (gastroparesis), it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty. (You can read that here in another blog article of mine: http://www.emilysstomach.com/2017/06/pyloric-stent-pyloroplasty.html)


This is a completed Nissen Fundoplication in Watercolors:
Source: By Dana Hamers - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=20453728
Source: http://en.wikipedia.org/wiki/Nissen_fundoplication


This is the Nissen Fundoplication Procedure:
Source: Original Artwork by James P. Gray, M.D. 2007 (author)



The doctor that I saw that the Mayo Clinic wanted me to have this surgery done so that it would stop my vomiting. However, he concluded that since I vomit so violently, I would undo the surgery. A mom who reads my blog and has a son with gastroparesis, was nice enough to share his story with me about the Nissen he had done. When my doctor said that it would stop vomiting, he was wrong. His story is below,


"Hi, my 17 year old son had the Nissen procedure last year. He too violently throws up. The surgery went well but he said out of his 33 surgeries it was the most painful after. He went through the recovery process not realizing until about a week after that he could not even swallow water without it coming right back up.

He lost weight quickly and was very dehydrated so at his check up appointment the hospitalized him. The Nissen was too tight and nothing was going to his stomach. The doctor did a scope and stretched the area. That helped for a bit but they had to go back and stretch it a second time.

That was the last stretch they had to do. They said the Nissen would make it almost impossible for him to throw up. Boy were they wrong. He still throws up most every time he eats. By the way he has GP (gastroparesis) and has an electric stimulator in his stomach. Amanda S."


I also know a few people with gastroparesis who have had this surgery done and they are miserable now. They are unable to vomit at all. That worries me, personally, because what if you get food poisoning and need to vomit to get it out? What do you do then?


"Gastroparesis Following Nissen Fundoplication And Hiatal Hernia Repair

Nissen fundoplication with hiatal hernia repair is the most reliable and most effective treatment of GERD or acid reflux disease. The procedure is also very safe with less than 1% complication rate. Gastroparesis or delayed gastric emptying is a poorly understood medical disorder. Gastroparesis results from abnormal gastro-duodenal motility resulting in nausea, vomiting, bloating, epigastric pain and early satiety. Gastroparesis can also contribute to acid reflux disease. GERD is a multi-factorial problem and is closely related to gastric motility. Indeed, gastric fundus compliance, relaxation, food accommodation and luminal pressure affects transient lower esophageal sphincter relaxation, TLESR. TLESR is believed to be the main cause of acid reflux. It is not surprising for gastroparesis patients to suffer from heartburn and other GERD related symptoms. In fact, both GERD and gastroparesis may represent different aspects of the same problem related to esophago-gastro-intestinal dysmotility.

Many GERD patients undergoing Nissen fundoplication and hiatal hernia repair surgery may also have undiagnosed gastroparesis. Around 40% of GERD patients suffer from delayed gastric emptying. Nissen fundoplication increases gastric emptying and is sometimes associated with dumping especially in children. Wrapping the fundus around the esophagus decreases gastric compliance possibly leading to increased gastric emptying. The same mechanism of action may also be at play in the case of sleeve gastrectomy. By resecting the gastric fundus, gastric compliance decreases and emptying increases. Consequently, Nissen surgery improves gastric emptying and it contributes to gastroparesis symptom resolution.

In a minority of patients, Nissen surgery is associated with post-operative gastroparesis symptom development. These patients develop nausea, bloating, and pain in the first few days after Nissen surgery. It is unclear whether the surgery itself causes de novo gastroparesis or if it exacerbates an already existing problem with gastric emptying. It has always been assumed that vagal nerve injury results in gastric stasis and failure of the pylorus to relax. Pyloromyotomy has also been advocated in vagotomy cases. Swanstrom et al published a study in 2009 in Archives of Surgery titled “Outcomes of Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease and Delayed Gastric Emptying”. He recommends the addition of pyloroplasty to Nissen fundoplication in cases of delayed gastric emptying. In my experience, pyloromyotomy, like other drainage procedures, has minimal effect on gastric emptying. Gastric emptying is a highly coordinated myo-electrical process. Many feedback signals, in addition to the vagus nerve, modulate this activity. It is unlikely that post-operative gastroparesis is the sole result of vagal nerve injury.

In 2004, a study published by Masclee et al, in the Annals of Surgery showed that laparoscopic fundoplication increases gastric emptying independent of vagal nerve function. The authors nicely showed that 10% of fundoplication patients developed vagal nerve dysfunction post-operatively without affecting gastric emptying or the efficacy of fundoplication in controlling acid reflux. The etiology of gastric stasis is following Nissen surgery remains unclear. There are no established treatment guidelines for gastroparesis. Medications, gastric pacing and drainage procedures are not effective solutions. Subtotal gastrectomy and gastric bypass are associated with poor outcomes. Longitudinal gastrectomy with or without duodeno-jejunostomy seems to be very effective in curing gastroparesis. I have developed this technique several years ago and I have had the chance to apply it on 4 patients so far. Last year, a young man with gastroparesis following fundoplication surgery at an outside institution presented to my office. I performed a longitudinal gastrectomy while preserving the fundoplication and antrum. His symptoms improved immediately. A post-operative UGI study on day one after surgery showed normal gastric emptying. The patient is 8-month post-op now and still doing great.

In summary, gastroparesis and gastric emptying remain poorly understood. However, a tailored longitudinal gastrectomy, even in the presence of a fundoplication, may be an effective and durable solution for gastroparesis. Additional studies are needed to establish this approach as the standard of care treatment for gastroparesis."
Source: http://houstonheartburn.com/gastroparesis-following-nissen-fundoplication-and-hiatal-hernia-repair/



Source: http://www.laparoscopicsurgeonmumbai.com/precautions-nissen-laparoscopic-fundoplication-surgery-gerd/



WebMD says,

"Surgery Overview

During fundoplication surgery, the upper curve of the stomach (the fundus) is wrapped around the esophagus camera and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle. This surgery strengthens the valve between the esophagus and stomach (lower esophageal sphincter), which stops acid from backing up into the esophagus as easily. This allows the esophagus to heal.

This procedure can be done through the abdomen or the chest. The chest approach is often used if a person is overweight or has a short esophagus.

This procedure is often done using a laparoscopic surgical technique. Outcomes of the laparoscopic technique are best when the surgery is done by a surgeon with experience using this procedure.

If a person has a hiatal hernia, which can cause gastroesophageal reflux disease (GERD) camera.gif symptoms, it will also be repaired during this surgery.



What To Expect After Surgery

If open surgery (which requires a large incision) is done, you will most likely spend several days in the hospital. A general anesthetic is used, which means you sleep through the operation. After open surgery, you may need 4 to 6 weeks to get back to work or your normal routine.

If the laparoscopic method is used, you will most likely be in the hospital for only 2 to 3 days. A general anesthetic is used. You will have less pain after surgery, because there is no large incision to heal. After laparoscopic surgery, most people can go back to work or their normal routine in about 2 to 3 weeks, depending on their work.

After either surgery, you may need to change the way you eat. You may need to eat only soft foods until the surgery heals. And you should chew food thoroughly and eat more slowly to give the food time to go down the esophagus.



Why It Is Done

Fundoplication surgery is most often used to treat GERD symptoms that are likely to be caused in part by a hiatal hernia and that have not been well controlled by medicines. The surgery may also be used for some people who do not have a hiatal hernia. Surgery also may be an option when:

Treatment with medicines does not completely relieve your symptoms, and the remaining symptoms are proved to be caused by reflux of stomach juices.

You do not want or, because of side effects, you are unable to take medicines over an extended period of time to control your GERD symptoms, and you are willing to accept the risks of surgery.

You have symptoms that do not adequately improve when treated with medicines. Examples of these symptoms are asthma, hoarseness, or cough along with reflux.



How Well It Works

In most people who have laparoscopic surgery for GERD, the surgery improves symptoms and heals the damage done to the esophagus.

Over time, some people have symptoms come back, have esophagitis come back, need to take medicine for symptoms, or need another operation.

Surgery can cause new and troublesome symptoms. Over time, some people have trouble swallowing, have increased flatulence (gas), and/or have trouble belching.




Risks or complications following fundoplication surgery include:

Difficulty swallowing because the stomach is wrapped too high on the esophagus or is wrapped too tightly.

The esophagus sliding out of the wrapped portion of the stomach so that the valve (lower esophageal sphincter) is no longer supported.
Heartburn that comes back.

Bloating and discomfort from gas buildup because the person is not able to burp.

Excess gas.

Risks of anesthesia.

Risks of major surgery (infection or bleeding).

For some people, the side effects of surgery-bloating caused by gas buildup, swallowing problems, pain at the surgical site-are as bothersome as GERD symptoms. The fundoplication procedure cannot be reversed, and in some cases it may not be possible to relieve the symptoms of these complications, even with a second surgery.




What To Think About

GERD can be annoying and even painful. But it is not a dangerous disease. For any GERD treatment to be worth trying, it needs to be very safe. For many people, especially those who have few problems taking medicine, surgery is not a good choice.

But when fundoplication surgery is successful, it may end the need for long-term treatment with medicine. When you are deciding between surgery and treatment with medicine, weigh the cost, risks, and potential complications of the surgery against the cost and inconvenience of taking medicine.




GERD: Which Treatment Should I Use?

Before surgery, additional tests will usually be done to be sure that surgery is likely to help cure GERD symptoms and to diagnose problems that could be made worse by surgery.

Second surgeries are harder to do, are less successful, and are more risky. So it is extremely important that the first procedure be considered carefully and be done by an experienced surgeon who is more likely to be successful the first time.



Surgery to treat GERD is rarely done on people who:

Are older adults, especially if they have other health problems in addition to GERD.

Have weak squeezing motions (peristalsis) in the esophagus. These motions are important to move food down the esophagus to the stomach. Surgery may make this problem worse, causing food to get stuck in the esophagus.

Have unusual symptoms that might be made worse by surgery.

In special cases, other surgeries such as partial fundoplication or gastropexy may be done instead of fundoplication surgery.



Source: http://www.bariatricinnovationsatl.com/acid-reflux-surgery



References and Citations:

Lundell L, et al. (2007). Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis. British Journal of Surgery, 94(2): 198-203.


Other Works Consulted:

Galmiche J-P, et al. (2011). Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD. JAMA, 305(19): 1969-1977.



Credits:

By: Healthwise Staff
Primary Medical ReviewerAdam Husney, MD - Family Medicine
Specialist Medical ReviewerPeter J. Kahrilas, MD - Gastroenterology

Current as of November 20, 2015"