Early detection and intervention in diabetic gastroparesis: Role of body surface gastric mapping

Abstract

Diabetic gastrointestinal neuropathy is a diabetes-related complication, associated with a complex interplay of hyperglycemic damage, autoimmune responses, oxidative stress, gastrointestinal hormones, and vascular insufficiency. Patients with diabetes should be monitored and therapeutic intervention introduced to prevent neuropathy due to diabetes prior to “the point of no return”. Determining gastric bioelectrical activity by body surface gastric mapping may be a promising option to monitor diabetic gastrointestinal neuropathy.

Key Words: Gastroparesis; Body surface gastric mapping; Gastric emptying breath test; Diabetes; Electrogastrography

Core Tip: Gastroparesis is a frequent and sometimes life-threatening complication of diabetes, but no appropriate method has been established to evaluate its early onset. The author has high expectations for the future potential of body surface gastric mapping in this area. The article reviews the paper published in the World Journal of Gastroenterology in 2024 and discusses its findings and implications.

TO THE EDITOR

I read with great interest the review article by Abdalla[1] about enteric neuropathy in diabetes. As she points out, diabetes is a global problem, and gastrointestinal neuropathy, a diabetes-related complication, is one of the most difficult conditions to treat.

Although a complex interplay of hyperglycemic damage, autoimmune responses, oxidative stress, gastrointestinal hormones and vascular insufficiency are associated with diabetic gastrointestinal neuropathy[1-3], there is no doubt that blood glucose control from early onset remains the basis of treatment. On the other hand, it is clear that some diabetic individuals develop neuropathy early in life, whereas others do not, making it interesting to determine how neuropathy is related to changes in the gut microbiota or their associated metabolites mentioned by Abdalla[1].

Among gastrointestinal neuropathies, gastroparesis is a frequent and sometimes life-threatening complication of diabetes. Early stage evaluation is important, not only because gastroparesis is associated with symptoms such as nausea, vomiting, bloating, and early satiety, but also because it has an important impact on nutritional status and glycemic control in diabetic patients[1]. Moreover, existing therapeutic approaches primarily target the enhancement of gastric motility; however, their outcomes remain suboptimal. This highlights the necessity for novel and early diagnostic methods for diabetic gastropathy. Just as it is difficult to deal with fibrosis in patients with non-alcoholic steatohepatitis once fatty liver has developed, it is similarly important to prevent neuropathy due to diabetes with therapeutic intervention prior to “the point of no return”. So, how can early-stage diabetic gastric dysmotility be monitored?

Esophagogastroduodenoscopy is a diagnostic modality generally used to identify organic diseases, it can also assess the presence of gastroparesis on a background of gastric hypomotility in patients with intragastric remnants[4]. Unless a patient is at high risk for gastrointestinal cancer, however, regular endoscopic monitoring in the absence of gastrointestinal symptoms is inefficient and not recommended considering the invasiveness of the procedure. In addition, endoscopy is not suitable for quantitative assessment of gastrointestinal motility.

Both direct and indirect methods are available for evaluating gastric motility emptying capacity. Direct methods include measurements of intragastric pressure, of a radiopaque marker and of a radioactive isotope, whereas indirect methods include breath tests[5]. Because all of these tests are invasive, involve exposure to radiation, or require a lengthy examination, there is a need for simpler, non-invasive testing methods. In addition, as mentioned earlier, the mechanisms by which diabetes causes enteric neuropathy are diverse. Thus, gastric motility may not show an overall decline; rather, neuropathy may begin in a specific area, followed by gradual propagation of the impairment. In other words, there is a need for an examination method that evaluates not only overall gastric emptying ability but provides a bird's eye view of the physiological movements of the stomach. Measurements of gastric bioelectrical activity based on body surface gastric mapping (BSGM) may be a promising option in the future.

BSGM is a novel non-invasive method for assessing gastric electrical activity. It records bioelectrical signals from the stomach through an array of electrodes placed on the skin’s surface. BSGM aims to detect and analyze the spatiotemporal patterns of gastric dysrhythmias, which are often associated with motility disorders like gastroparesis. By improving on traditional electrogastrography (EGG), which has limitations in sensitivity and accuracy, BSGM captures more detailed data, potentially offering better diagnostic insights into gastric functional disorders[6]. Recently, a BSGM approach, involving multiple EGG electrodes, showed promise in capturing both the frequency and spatial changes of gastric slow waves, as well as strongly correlating with symptoms[7,8]. Current studies are limited to physiological assessment in mapping and to reporting the effects of loading with diet and drugs[7,9,10]. Furthermore, BSGM faces several challenges that need to be overcome, such as anatomical variability, weak signal detection, noise and artifacts, reliance on complex algorithms, distinguishing gastric from colonic activity, and issues with electrode placement and skin contact[6]. I expect, however, that detailed pathophysiological assessment of diabetic gastroparesis will be possible in the near future. In addition, as BSGM is a simple and non-invasive method, it may be introduced to monitor for diabetes, leading to early therapeutic intervention. Specifically, studies using BSGM are expected to include comparisons of gastric motility based on glycemic control status and disease duration in diabetic patients, spatial recognition of gastric motility during fasting in relation to gastrointestinal hormones, insulin, and blood glucose levels, as well as comparisons between BSGM and currently used gastric emptying and gastric tolerance tests.