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Gastroparesis

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Ruth Hodgson

on 30 May 2015

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Transcript of Gastroparesis

Gastroparesis is a syndrome of objectively delayed gastric emptying in the absence of a mechanical obstruction and cardinal symptoms of nausea, vomiting, early satiety, bloating and/or upper abdominal pain.
Definition
The bloated patient:
Considerable symptom
overlap
Large population-based study
3604 potential cases identified
83 fulfilled diagnostic criteria for gastroparesis

Epidemiology
Nausea (93%)
Vomiting (68 – 84%)
Abdominal pain (46-90%)
Early satiety (60-86%)
Post prandial fullness
Bloating
Weight loss (1)
Symptoms
Viral
Aetiology
Aetiology
History and
Examination
Evaluation
Ruth Hodgson
The Prince Charles Hospital
GESQ Noosa May 2015

Camilleri M et al. Am J Gastroenterol 2013; 108: 18
Age-adjusted incidence
2.4 per 100 000 person-years for men
9.8 per 100 000 person-years for women

Age-adjusted prevalence
9.6 per 100 000 persons for men
38 per 100 000 persons for women

Jung et al Gastroenterol 2009; 136:1225
416 pts with gastroparesis
Idiopathic: early satiety,
postprandial fullness, pain
Diabetic: retching, vomiting (2)
335 pts – bloating
> Mild 76%
Severe 41% (3)
Abdominal pain
Predominant symptom 18% (4)
(2) Parkman et al. Clin Gastroenterol Hepatol 2011; 9: 1056,
(3) Hasler et al. Am J Gastroenterol 2011; 106: 1492,
(4) Camilleri. Neurogastroenterol Motil 2006; 18:499

Population based studies in DM pts – symptoms 11-18% (2)
DM pts in referral centres – UGI symptoms > delayed gastric emptying 50-65% (3)
Cumulative incidence of gastroparesis in 10 yrs – T1DM 5%, T2DM 1% (cf 0.2% controls) (4)
Acute hyperglycaemia (>11.1 mmol/L) may also contribute to delayed gastric emptying
Diabetic
Postsurgical
Intended or accidental injury to vagus nerve (Billroth II gastrectomy, fundoplication, lung or heart transplantation)
Variceal sclerotherapy and botulinum toxin injection
-Norwalk virus and rotavirus (1)
- CMV, EBV, VZV
– severe dysautonomia (or selective cholinergic dysautonomia) (2)
2 Bytzer et al. Arch Intern Med 2001; 161: 1989.
3 Jones et al. Diabetes Care 2001; 24: 1264.
4 Parkman et al Clin Gastroenterol Hepatol 2011; 9: 1056.
Medications
(1) Bityutskiy et al. Am J Gastroenterol 1997; 92: 1501.
(2) Lobrano et al. Neurogastroenterol Motil 2006; 18: 162.
A-2-adrenergic agonists (eg clonidine)
Tricyclic antidepressants
Calcium channel blockers
Dopamine agonists
Muscarinic cholinergic receptor antagonists
Octreotide
Glucagon-like peptide (GLP)-1 agonists and amylin analogues
Phenothiazines
Cyclosporine (but not tacrolimus)
Abell et al.Am J Gastroenterol 2008;103:753

Exclude
mechanical
obstruction
-
Scintigraphic gastric emptying
Stop medications that can affect gastric emptying 48hrs prior (or longer)
Treat hyperglycaemia (<17mmol/L)
Low fat egg-white meal labelled with 99mTc (liquid only used if dumping syndrome suspected)
Scans – immediate, 1, 2, 4h
Delayed gastric emptying: retention >10% at 4 hours and/or >60% at 2 hours.
Assess gastric motility
Alternatives to
Scintigraphy
Simultaneously measures phasic pressure amplitudes, temperature, and pH as it travels (1)
Sensitivity 59-86%, specificity 64-81% (2)
Often emptied after 5 hrs since requires fasting migrating motor complex (MMC). ~30% healthy subjects emptied with coordinated postprandial antral contrations – potential information to exclude a myopathic disorder (3)
labeled acetate, octanoic acid breath tests or spirulina have been used (1)
At 80% specificity – combined 89% sensitivity [13C spirulina] (2)
Performed at bedside
13C breath testing

Differential
Diagnosis
Psychiatric disease – can be difficult
Rumination syndrome
Intellectually challenged children
- Adolescents and adults
Highly stressed, high achievers or perfectionists
Effortless regurgitation of undigested
food within minutes of starting or completing meal ingestion
Normal gastric emptying
Functional dyspepsia – 25-40% adults & children (1)
Cyclic vomiting syndrome
Superior Mesenteric Artery Syndrome
Investigation
Usual stuff
Differentiate myopathic process (eg amyloid & scleroderma) from neuropathic process (eg DM, amyloid neuropathy, idiopathic autonomic neuropathy)
Gastroduodenal
manometry
Autonomic testing
Differentiate a preganglionic (central) from peripheral neuropathy
Cutaneous electrogastrogram (EGG)
Single photon emission computed tomography (SPECT)
Full thickness gastric and small intestinal biopsy
- 101 pts with refractory and unexplained N & V
- high incidence of SI morphologic abnormalities (primarily neuropathies)
– heterogenous including myentric inflammation, decreased innervation, reduced number of interstitial cells of Cajal (ICC), muscle fibrosis (1)
Research tools

1 Abel et al.Surgery 2009; 145: 476

1Kuo et al.Neurogastroenterology 2004; 16:666.
2Agency for Healthcare Research and Quality (AHRQ).
3Thumshirn et al. Am J Gastroenterol 1997; 92: 1496.
When is it delayed gastric emptying?
Gastroparesis?
Not gastroparesis
– just greed
Is the patient constipated?
eMR of 149 patients presenting
with nausea and vomiting
77 (52%) had evacuation disorder: 68 had findings
consistent with dyssynergic defaecation
If the patient was going to have delayed motor
function it was equally likely this would
be delayed colonic transit or delayed
gastric emptying

Kolar et al. Gastroenterol Motil 2014;26:131-8

gastroparesis

constipation

Functional dyspepsia
Abell et al.Am J Gastroenterol 2008;103:753

Gastric emptying
1Lee et al. Gut 2000; 46: 768.
2Szarka et al. Clin Gastroenterol Hepatol 2008; 6: 635.

Wireless motility capsule
(WMC)
(1) Bredenoord et al. Clin Gastroenterol Hepatol 2003;1:264-72
Which treatment works?
Principles
- Correction of biochemical and physiological abnormalities
- Ongoing treatment
Medical
Endoscopic
Surgical
Correction of electrolytes and glycaemic control
Antiemetics
Prokinetics
Pain relief without narcotics (eg tramadol)
Venting gastrostomy + jejunostomy
New approaches
- Surgery
- Endoscopic botox injection
- Gastric electrical stimulation

Treatment
Small, frequent low-fat meals consisting of complex CHO
Post pyloric enteral nutrition
Parenteral nutrition

Nutrition
Glycaemic control
Hyperglycaemia per se may impair gastric emptying
Hyperglycaemia may impair response to prokinetics (1)
(1) Jones et al. Am J Gastroenterol 1999;94:2074-9

Metoclopramide
- Prokinetic – ACh release via 5-HT4 R
(enteric cholinergic neurons), dopamine D2 R antagonist (myenteric plexus), muscarinic R sensitisation (direct smooth m contraction)
-Central antiemetic – D2 and serotonin
(5-HT3) R antagonism – vagus and brainstem
Domperidone
- D2 R antagonist

Pharmacology
Pharmacology
Cisapride
- 5-HT4 agonist
- Facilitates release of ACh from myenteric cholinergic nerves throughout gut
ATI-7505
Erythromycin
Tegaserod – 5-HT4 agonist
Prucalopride
ABT 229, mitemcinal (GM-611)
Ghrelin
Sildenafil – PDE 5 inhibitor
Paw paw

Botox
4 x 25U injected into pylorus vs placebo (1)
-12 patients (2 DM, 10 idiopathic)
-GE solids improved
-No improvement in symptoms vs placebo
Open label observational study
-43% improvement
-Mean 5 months
-Vomiting as major symptom predicted no response (2)
(1) Arts et al. Gastroenterology 2005;128:A81.
(2) Bromer et al. Gastrointesti Endosc 2005;61:833-9

Non medical treatment
Required in 2-5%
Gastrostomy or jejunostomy
-Venting
-Feeding
Surgery
-Few data
near total gastrectomy
Gastrojejunostomy
Roux en Y gastric bypass
Feeding stoma

Gastric Electrical Stimulation
Three principal methods described
1 Gastric electrical pacing
-Aims to reset a regular slow-wave rhythm
2 high-frequency gastric electrical
stimulation licensed and in use
3 Sequential neural electrical
stimulation

Establish diagnosis
Treat concomitant conditions eg constipation
Establish nutritional and physiological stability
Nutritional support
Drugs are mainstay of treatment
Endoscopic and surgical interventions are reserved for most severe cases
Conclusion
https://prezi.com/dclwl8jipwmy/gastroparesis/

Thank you
Sokyan et al. dig dis Sc 1998;43:2398-404

(1) Sokyan et al. Dig Dis Sci 1998; 43: 2398,
Camilleri et al
https://prezi.com/dclwl8jipwmy/gastroparesis/
Aetiology
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