Kurdistan Board GEH/GIT SurgeryKurdistan Board GEH/GIT SurgeryWeekly J ClubWeekly J ClubSupervised by:Supervised by:

Dr. Mohamed AlshekhaniDr. Mohamed Alshekhani

Introduction:Introduction: There are sex differences in GI motility in health & disease, likely There are sex differences in GI motility in health & disease, likely

the effect of female hormones. the effect of female hormones. Estrogen/ progesterone receptors are found throughout GIT & Estrogen/ progesterone receptors are found throughout GIT &

influence its motility.influence its motility. Estrogen is needed to prime & enhancethe inhibitory effects of Estrogen is needed to prime & enhancethe inhibitory effects of

progesterone.progesterone. These hormones mediate GI motility by eliciting changes in nitric These hormones mediate GI motility by eliciting changes in nitric

oxide–containing neurons in the myenteric plexus&affecting the oxide–containing neurons in the myenteric plexus&affecting the number / function of mast cells in GI mucosa.number / function of mast cells in GI mucosa.

Fluctuations of female hormones during the menstrual cycle, Fluctuations of female hormones during the menstrual cycle, pregnancy, menopause/perimenopausal transition, causes pregnancy, menopause/perimenopausal transition, causes significant differences in GI motility. significant differences in GI motility.

Introduction:Introduction: Menstruation is an inflammatory state characterized by increases Menstruation is an inflammatory state characterized by increases

in proinflammatory cytokines (eg, TNF-a) & other mediators before in proinflammatory cytokines (eg, TNF-a) & other mediators before menstrual flow,linked to declining progesterone in late luteal phasemenstrual flow,linked to declining progesterone in late luteal phase

During pregnancy, there is a progressive substantial increase in During pregnancy, there is a progressive substantial increase in progesterone & estrogen. progesterone & estrogen.

After menopause, the opposite occurs: estrogen / progesterone After menopause, the opposite occurs: estrogen / progesterone drop significantly but at what age & pattern of the drop are variable drop significantly but at what age & pattern of the drop are variable referred to as perimenopause phase.referred to as perimenopause phase.

The effect of female hormonal stages (ie, menses,regnancy, The effect of female hormonal stages (ie, menses,regnancy, menopause) on GI motility is not factored into treatment plans. menopause) on GI motility is not factored into treatment plans.

To more accurately & effectively manage GI dysmotility for both To more accurately & effectively manage GI dysmotility for both men/women, providers should better understand the sex men/women, providers should better understand the sex differences in both healthy/ GI dysmotility conditions. differences in both healthy/ GI dysmotility conditions.

Sex difference in gastropariesisSex difference in gastropariesis Gastroparesis affects women more commonly than men for all main Gastroparesis affects women more commonly than men for all main

subtypes: idiopathic (80%), diabetic (76%), postsurgical (89%).subtypes: idiopathic (80%), diabetic (76%), postsurgical (89%). Women with gastroparesis have slower gastric-emptying & higher Women with gastroparesis have slower gastric-emptying & higher

gastric retention at 4 hours than men.gastric retention at 4 hours than men. Women with gastroparesis tend to be more symptomatic than men. Women with gastroparesis tend to be more symptomatic than men. Women with diabetic gastroparesis report significantly more Women with diabetic gastroparesis report significantly more

nausea, early satiety, postprandial excessive fullness&loss of nausea, early satiety, postprandial excessive fullness&loss of appetite than men. appetite than men.

Women with idiopathic gastroparesis report more nausea, stomach Women with idiopathic gastroparesis report more nausea, stomach fullness, inability to finish a meal, postprandial excessive fullness, fullness, inability to finish a meal, postprandial excessive fullness, bloating, abdominal distention&constipation than men.bloating, abdominal distention&constipation than men.

No sex differences in vomiting&retching in either diabetic & No sex differences in vomiting&retching in either diabetic & idiopathic gastroparesis.idiopathic gastroparesis.

Sex difference in gastropariesisSex difference in gastropariesis Healthy women have slower gastric-emptying, prolonged fundic Healthy women have slower gastric-emptying, prolonged fundic

relaxation, decreased antral contractility& increased sensitivity, relaxation, decreased antral contractility& increased sensitivity, making women more susceptible to onset & symptoms of GP.making women more susceptible to onset & symptoms of GP.

The prevalence/severity of symptoms of diabetic GP are higher The prevalence/severity of symptoms of diabetic GP are higher among obese women &long-standing, poorly controlled DM& at among obese women &long-standing, poorly controlled DM& at increased risk of developing DM due to its proinflammatory effects. increased risk of developing DM due to its proinflammatory effects.

The adipose tissue of obese women secrete more estrogen. The adipose tissue of obese women secrete more estrogen. Associated factors for women with idiopathic gastroparesis include Associated factors for women with idiopathic gastroparesis include

smoking, drinking alcohol, H/O migraine headaches.smoking, drinking alcohol, H/O migraine headaches. There are some known sex differences in the response to certain There are some known sex differences in the response to certain

medications &investigational treatments for gastroparesis. medications &investigational treatments for gastroparesis. Despite superior responses in women for some therapies, symptoms Despite superior responses in women for some therapies, symptoms

are less likely to improve over time in women. are less likely to improve over time in women. Male sex is an independent predictor of symptomatic improvement & Male sex is an independent predictor of symptomatic improvement &

associated with >* 2 improvement over women.associated with >* 2 improvement over women.

Sex difference in gastropariesisSex difference in gastropariesis Premenopausal gastroparesis Premenopausal gastroparesis women not on oral contraceptive, women not on oral contraceptive,

nausea / early satiety worsen during the luteal phase of the nausea / early satiety worsen during the luteal phase of the menstrual cycle. menstrual cycle.

Gastroparesis, especially if severe, is a relative contraindication for Gastroparesis, especially if severe, is a relative contraindication for pregnancy because of an increased risk of maternal morbidity & pregnancy because of an increased risk of maternal morbidity & poor perinatal outcomes.poor perinatal outcomes.

Postmenopausal women tend to have less severe gastroparesis Postmenopausal women tend to have less severe gastroparesis symptoms.symptoms.

Conclusion:Conclusion: These sex differences may affect diagnostic &treatment strategies These sex differences may affect diagnostic &treatment strategies

of upper GI dysmotility conditions:of upper GI dysmotility conditions: Screening guidelines for Barrett’s esophagus excluded women. Screening guidelines for Barrett’s esophagus excluded women. A lower LES pressure cutoff considered for women during A lower LES pressure cutoff considered for women during

esophageal manometry. esophageal manometry. Different gastric-emptying times could be set for men / women for Different gastric-emptying times could be set for men / women for

the diagnosis of gastroparesis. the diagnosis of gastroparesis. Female patients with either GERD or gastroparesis are more Female patients with either GERD or gastroparesis are more

symptomatic during the luteal phase of their menstrual cycle. symptomatic during the luteal phase of their menstrual cycle. There are sex differences in the response to common therapies.There are sex differences in the response to common therapies.