Cellular Changes in Diabetic and Idiopathic Gastroparesis Madhusudan Grover, Gianrico Farrugia, Matthew S. Lurken, Cheryl E. Bernard, Maria Simonetta Faussone–Pellegrini, Thomas C. Smyrk, Henry P. Parkman, Thomas L. Abell, William J. Snape, William L. Hasler, Aynur Ünalp–Arida, Linda Nguyen, Kenneth L. Koch, Jorges Calles, Linda Lee, James Tonascia, Frank A. Hamilton, Pankaj J. Pasricha  Gastroenterology  Volume 140, Issue 5, Pages 1575-1585.e8 (May 2011) DOI: 10.1053/j.gastro.2011.01.046 Copyright © 2011 AGA Institute Terms and Conditions

Figure 1 Representative images for PGP9.5 immunoreactivity used as a general neuronal marker, nNOS immunoreactivity, and VIP immunoreactivity. (A) PGP9.5 immunoreactivity. The image on the left is from a control and the image on the right is from a patient with idiopathic gastroparesis with <25% decrease of PGP9.5 immunoreactivity in the circular muscle (cm) and longitudinal muscle (lm) and in the myenteric plexus (mp) region. (B) nNOS immunoreactivity. The image on the left is from a control, and the images in the middle and on the right are from patients with diabetic gastroparesis and idiopathic gastroparesis, respectively, showing decreased nNOS immunoreactivity in the CM and LM and in the MP region. (C) VIP immunoreactivity. The image on the left is from a control, and the images in the middle and on the right are from patients with diabetic gastroparesis and idiopathic gastroparesis, respectively, showing decreased VIP immunoreactivity in the CM and LM and in the MP region. Scale bar = 100 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Figure 2 Representative images for Kit immunoreactivity as a marker for ICC. (A) Control. (B) Diabetic gastroparesis with decreased ICC. (C) Idiopathic gastroparesis with decreased ICC. cm, circular muscle layer; lm, longitudinal muscle layer; mp, myenteric plexus region. Scale bar = 100 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Figure 3 Representative images for smoothelin immunoreactivity as a marker for smooth muscle cells and trichrome-stained sections as a marker for fibrosis. (A and D) Controls. (B) Diabetic gastroparesis with decreased smoothelin immunoreactivity. (C) Idiopathic gastroparesis with decreased smoothelin immunoreactivity. Red signal represents smoothelin IR, and blue signal is 4′,6-diamidino-2-phenylindole (DAPI) counterstain. (E) Diabetic gastroparesis with fibrosis. (F) Idiopathic gastroparesis with fibrosis. cm, circular muscle layer; lm, longitudinal muscle layer; mp, myenteric plexus region. Scale bar = 100 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Figure 4 Images of CD45 and CD68 immunoreactivity. (A) CD45 immunoreactivity in a control. (B) CD68 immunoreactivity from the same section as A. (C) CD45 and CD68 merged. (D) CD45 immunoreactivity from diabetic gastroparesis with increased number of CD45-positive cells. (E) CD68 immunoreactivity from the same section as D. (F) CD45 and CD68 immunoreactivity. Arrowheads point to CD45-positive, CD68-negative immunoreactivity. Arrows point to colocalized immunoreactivity. cm, circular muscle layer; lm, longitudinal muscle layer; mp, myenteric plexus region. Scale bar = 100 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Figure 5 Diabetic gastroparesis and idiopathic gastroparesis. A–C are from patients with diabetic gastroparesis, and D and E are from patients with idiopathic gastroparesis. (A) An ICC with large vacuoles in the cytoplasm and a discontinuous, thick basal lamina (asterisks). smc, smooth muscle cell. (B) Smooth muscle cells immersed in a fibrotic stroma and separated, except for small junctional areas, most of which are gap junctions (asterisks). (C) Nerve bundle surrounded by a very thick basal lamina and numerous collagen fibers. The nerve endings are empty. (D) A presumptive ICC with swollen mitochondria and intracytoplasmatic lamellar bodies (asterisk) near a small nerve bundle (n). (E) Nerve bundle endowed in a fibrotic capsule. The nerve endings (n) are filled with filaments and do not contain synaptic vesicles. SMC immersed in a fibrotic stroma and far away from each other. Sch, Schwann (glial) cell with a clear cytoplasm and several lipofuscinic bodies. Bar: A, B, D, and E = 1 μm; C = 0.8 μm. Please refer to Supplementary Figure 10 for electron microscopy controls. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 1 Scatter plot showing quantification of PGP9.5-positive nerve fibers for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis in the circular muscle layer. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 2 Scatter plot showing quantification of (A) nNOS-positive neurons in the myenteric plexus and (B) nNOS-positive nerve fibers in the circular muscle layer for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 3 Scatter plot showing quantification of VIP-positive nerve fibers in the circular muscle layer for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 4 Representative images for substance P immunoreactivity (SP-IR). (A) Control. (B) Tissue from a patient with diabetic gastroparesis with increased SP-IR in circular muscle (cm) and longitudinal muscle (lm) and in the myenteric plexus (mp) region. (C) Tissue from a patient with diabetic gastroparesis with decreased SP-IR in the CM and LM and in the MP region. (D) Tissue from a patient with idiopathic gastroparesis with decreased SP-IR in the CM and LM and in the MP region. (E) Tissue from a patient with idiopathic gastroparesis with increased SP-IR in the CM and LM and in the MP region. Scale bar = 100 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 5 Scatter plot showing quantification of substance P–positive nerve fibers in the circular muscle layer for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 6 Upper panels are representative images of S100β immunoreactivity as a marker for glial cells and lower panels are representative images of tyrosine hydroxylase immunoreactivity (TH-IR). (A and D) Controls. (B) Tissue from a patient with diabetic gastroparesis with decreased S100β-IR in circular muscle (cm) and longitudinal muscle (lm) and in the myenteric plexus (mp) region. (C) Tissue from a patient with idiopathic gastroparesis with decreased S100β-IR in the CM and LM and in the MP region. (E) Tissue from a patient with diabetic gastroparesis with decreased TH-IR in the CM and LM and in the MP region. (F) Tissue from a patient with idiopathic gastroparesis with decreased TH-IR in the CM and LM and in the MP region. Scale bar = 100 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 7 Scatter plot showing quantification of punctate tyrosine hydroxylase–positive labeling in the myenteric plexus for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 8 Scatter plot showing quantification of ICC in the circular muscle layer for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 9 Scatter plot showing quantification of CD45 staining cell bodies for controls, patients with idiopathic gastroparesis, and patients with diabetic gastroparesis in the (A) myenteric plexus and (B) circular muscle layer. Symbols represent individual patients. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions

Supplementary Figure 10 Electron microscopy of normal stomach. (A) Two ICC contacting each other. (B) Nerve fibers with several nerve endings (n), all of which contain many large granular vesicles. (C) Arrow indicates a contact between an ICC and a smooth muscle cell (smc). (D) A nerve fiber with several nerve endings (n), 2 of which are filled with large granular vesicles. Scale bars: A = 1 μm; B and C = 0.4 μm; D = 0.6 μm. Gastroenterology 2011 140, 1575-1585.e8DOI: (10.1053/j.gastro.2011.01.046) Copyright © 2011 AGA Institute Terms and Conditions