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Gastroparesis: Inpatient
Management
Canadian Society of Hospital Medicine
IL Epstein, MD, FRCPC
Assistant Professor
Department of Medicine, Dalhousie University
Friday Sept 29, 2017
Disclosures
2017 Ad Board Attendee:
Takeda
Abbvie
No conflicts with any products discussed in
this presentation
Objectives
1. Describe the presentation & symptoms of
gastroparesis in hospitalized patients
2. Demonstrate an approach to diagnosis of
gastroparesis
3. Appraise therapeutic options for
management of complex inpatient
gastroparesis
Case
55 yr old female
PMH Chronic back pain, DM, HTN
Meds: Glyburide, ASA, Ramipril, Metoprolol,
ASA, Hydromorphone
Admitted with UTI, severe nausea
Since admission refractory nausea, frequent
vomiting, abdominal pain
Refractory to anti-emetics; labile sugars;
unable to discharge
Symptoms
Nausea (93%)
Vomiting (68-84%)
Abdominal pain (46-90%)
*rarely the only / predominant symptom
Early satiety (60-86%)
Postprandial fullness, bloating, weight loss
Differential Diagnosis
Functional dyspepsia
Mechanical obstruction
Rumination
CVS
Cannabinoid hyperemesis syndrome
Eating disorder
Pathophsyiology
Often Multifactorial
Gastric “neuropathy”; rarely myopathy
Sensory & motor dysfunction
Vagal injury may be cause, but rare, and not a
factor in all cases
Pathophysiology
https://www.slideshare.net/kaj4/gut-motility-lecture
https://www.slideshare.net/suadboulevardez/chapter-17-gitmod
https://www.slideshare.net/wenyelin/gut-hormone-and-its-implication-in-glucose-homeostasis-11661727
Gastric Emptying
http://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/emptying.html
Causes
3 main categories
Idiopathic (includes neurologic disease,
autoimmune)
Diabetic (symptoms worse in type 1)
Post-surgical
Others (*inpatients, often reversible):
Hyperglycemia (>12mM/L)
Post-viral (*CMV, EBV, VZV)
Medications
Medications
TCAs
Alpha-2-agonists (clonidine), CCBs
Dopamine agonists, muscarinic cholinergic
receptor antagonists
Octreotide
Phenothiazines
Cyclosporine
GLP1 Analogs (Liraglutide)
Opioids!
Medications: Opioids
Curr Treat Options Gastro (2016) 14:478–494
Medications: Opioids
Stomach & colon have highest numbers of mu
receptors1
Constipation most common GI adverse event, but
nausea, vomiting, bloating, GERD also common
Occurs with mixed agonists/antagonists as well
(ex. buprenorphine used in opiate detox)2
1. Curr Treat Options Gastro (2016) 14:478–494 2. Addiction. 2007 Mar;102(3):490-1
60-year-old on long-term morphine for chronic back pain, presenting with acute
abdominal painThe American Journal of the Medical Sciences Volume 350, Number 3, September 2015
Diagnosis
To establish a diagnosis patient must have
1. Symptoms
2. Gastric outlet obstruction ruled out
3. Documented delayed gastric emptying
Clinical guideline: management of gastroparesis.
Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.
Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.
Diagnosis: Key Tests
Gastric emptying study
4 hr solid phase gastric emptying
UGI series/Gastroscopy
Exclude mechanical obstruction (e.g. small bowel
mass, SMA syndrome)
Retained food after overnight fast suggestive
Other diagnostic tests
Capsule
Gastric motility study
Breath test
Gastric emptying study
Scintigraphic gastric emptying of solids
ie Tc sulfur colloid labeled egg salad sandwich
Most reliable parameter is gastric retention of
solids at 4 hours
Completed off medications that affect gastric
emptying > 48 hrs before testing
Gastric images obtained during simultaneous assessment of gastric emptying and accommodation. Hrair
P. Simonian et al. J Nucl Med 2004;45:1155-1160
(c) Copyright 2014 SNMMI; all rights reserved
Lab tests
CBC
Fasting glucose; A1c
Albumin
TSH
Consider AI workup+/- viral or paraneoplastic
workup
Management Principles
Modify what you can:
Tight glycemic control
Remove potential meds
Diet
Prokinetics
Symptom control: Anti-emetics
Tubes: Nutrition +/- Venting
Compassionate: Electrical stimulation
Management: Diet/lifestyle
Avoid:
fat (slows gastric emptying)
nondigestible (insoluble) fibre – requires effective
interdigestive antral motility
carbonated beverages (increase distension)
EtOH & smoking (decrease antral contractility)
Small, frequent meals (4-5/day)
Liquid meals if intolerant of solids
emptying of liquids is often normal
Management: Prokinetics
Metoclopramide
dopamine-2 receptor antag, 5-HT4 ag, weak 5-
HT3 receptor antag
↑ gastric antral contractions, ↓ postprandial fundus
relaxation
SEs: anxiety, restlessness, depression, ↑PRL, ↑QT
interval, dystonia (0.2%), tardive dyskinesia (1%)
Domperidone
dopamine 2 antagonist
SEs: ↑PRL, check QT interval
Management: Prokinetics
Erythromycin: 3rd line
Motilin agonist; causes high amplitude propulsive
gastric contractions
Can be used 3rd line after domperidone or
metoclopramide
Liquid TID 40 – 250 mg ac meals
Works best IV
≤4 weeks at a time: tachyphylaxis
SEs: ↑QT, abdo pain, ototoxicity, sudden death
No trials for azithromycin but might be as good
Management: Prokinetics
Cisapride
5HT4 Agonist
10-20 mg QID ac meals
Stimulates antral and duodenal motility which is
maintained long term
Major drug interactions: macrolides, antifungals,
phenothiazine
Resulted in cardiac arrhythmia and death: QT
interval
Special access Health Canada only; need to
monitor QT; ensure <450 msec
Management: Prokinetics
Prucalopride
5HT4 agonist
dose of 1 to 4 mg OD
safe and well tolerated
Management: Prucalopride
RCT: 34 pts with gastroparesis, 6 with DM
prucalopride 2 mg OD vs. placebo
4 weeks of therapy; 2-week washout, then
crossover
Gastric half-emptying time:
Signficant decrease in prucalopride group: 87.9
minutes vs. 118, P < .05
Also reduced scores for nausea/vomiting,
fullness/satiety, bloating/distension, and QOL
1 episode of intestinal volvulus, 1 diarrhea
resulting in discontinuationhttp://www.firstwordpharma.com/node/1327032#axzz4thfvA4RM
Management: Antiemetics
Antihistamines: e.g. Diphenhydramine
12.5 mg orally / IV q6-8h
5HT3 antagonists
ondansetron 4 - 8 mg TID
Management: refractory
symptoms
percutaneous endoscopic gastrostomy tube
decompress upper GI tract
Reduces need for hospitalization for acute
exacerbations of dysmotility
percutaneous endoscopic jejunostomy tube
enteral nutrition
unintentional weight loss 10% of more / 3-6 mos,
or repeated hospitalizations
Tube Selection
Tube Use Limitations
NG Gastric decompression
in acute mgmnt
Not long term;
uncomfortable; gastric
feeding
NE Trial feeding to see if
small bowel feeding
tolerable
Not long term; Migration
of tube particularly with
vomiting
PEG Venting, decompression,
drainage
Gastric feeding
PEG-J Venting and small bowel
feeding
Migration of tube; pyloric
obstruction
J Small bowel feeding No G venting
PEG and J Two sites – one for
venting and nutrition
Increased risk leaking,
infection
Clinical guideline: management of gastroparesis.
Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.
Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.
Management: Gastric electrical
stimulation
high-frequency gastric electrical stimulation
(12/minute)
compassionate treatment for refractory nausea &
vomiting
Systematic review: improves symptom severity &
gastric emptying a subset of pts (diabetic)
Gastric pacing: regular slow-wave rhythm
Impractical - external current source too large
Lal et al. Gastric electrical stimulation with the Enterra system: a systematic review. Gastroenterology research and practice 2015;1.
Take Home Points
1. Gastroparesis can cause severe
symptoms; suspect in diabetics, post op and
with opioids
2. Diagnostic work up includes gastroscopy,
UGI series, gastric emptying study
3. Modify what you can – glycemic control,
meds, diet
4. Prokinetics, diet and time are mainstays of
therapy
Questions
Recommended