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GASTROPARESIS
September 12, 2015SGNA
GASTROPARESIS
• Definition: a disorder in which patients exhibit signs and symptoms of delayed gastric emptying without an anatomic cause (obstructing ulcer, inflammatory stenosis, malignancy)
Causes of Gastroparesis
• Systemic disorder: diabetes mellitus, muscular dystrophy, amyloidosis, scleroderma
• Idiopathic: post-viral• Post-surgical: vagotomy, fundoplication
Symptoms of Gastroparesis
• Nausea• Vomiting• Abdominal pain• Early satiety• Heartburn• Dysphagia
CASE NM-1
• 30 YO female transferred to UH with nausea/vomiting
• “Flu” symptoms 4 mo prior• Hospitalized 2x in Ft Wayne:GB US, Abd CT,
HIDA, EGD all negative• Serology: mono, hep B, ANA: negative• Enteroclysis: “mucosal thickening in jejunum”
CASE NM- 2
• Exploratory lap: neg; feeding J tube, appy• Small intestinal Bx: neg• Transfer to UH• PMH: facial herpes zoster 2 yr PTA• Physical Exam: normal; normal liver and
spleen
CASE NM-3
• Lab: ALT 139, AST 36, GGTP 99• CMV (IgM) Pos 1:80 titer• GE scan: borderline slow gastric emptying• ID consult: transient viral illness
CASE NM-4
• Small intestinal manometry: abnormal MMC• EGG: abnormal: no increase in post-prandial
3 cpm activity• EGD: normal• Histology: acute/chronic inflammation• Antral Bx viral culture: CMV
Case NM-5
• Patient eating, discharged home; N/V return• Treatment with E-mycin, Reglan ineffective• EGD (6 mo after onset of Sx): NL; antral Bx
culture: CMV• 9 mo after onset of Sx: Rx with leuprolide
CASE NM- 6
• Good response to leuprolide: eating well, no N/V
• MONTH 13: leuprolide stopped• Month 17: hosp at IU with N/V, abd pain;
surgical J tube, decompression g tube• MONTH 30: Mayo Clinic: delayed gastric
emptying, delayed colon transit• Transient response to cisapride
CASE NM- 7
• Hosp IUMC with abdominal pain; colonoscopy shows ulcers: Bx pos CMV culture
• Rx with gancyclovir: colon ulcers heal, pain improves, vomiting and tube feeding continue
• Rx with domperidone: no response• Rx with leuprolide: no improvement
CASE NM-8
Gastric pacemaker implanted 8 yr after onset of Sx.Patient does well over next two years; J tube and G tube removed two years later.Patient require high current output from pacemaker and requires replacement every two years.
FACTORS REGULATING GI MOTILITY
• Intrinsic properties of visceral smooth muscle• Intrinsic and extrinsic nervous system• Gastrointestinal hormones
MOTOR FUNCTIONS OF THE STOMACH
• Accomodation• Mixing• Emptying• Sensation
ASSESSMENT OF GASTRIC EMPTYING
• Nuclear scan• Endoscopy• Ultrasound• “SMART” pill
PROBLEMS WITH NUCLEAR SCINTIGRAPHY
• Need standardized meal• Liquids empty faster than solids• Proteins and carbohydrates empty faster than
fats• Digestible solids empty faster than digestible
solids
ASSESSMENT OF GASTRIC ACCOMODATION
• SPECT scan• Barostat
ASSESSMENT OF GASTRIC SENSATION
• Satiety test
TREATMENT OF GASTROPARESIS
• Diet: low fat, low residue; supplements• Medications: avoid anticholinergics, narcotics• Promotility agents• Antiemetics• GJ tube feeding• TPN• Gastric electrical stimulation
PROMOTILITY AGENTS
• Reglan: FDA advisory: 3 months• E-mycin: suspension expensive• Domperidone: not FDA approved, insurance
coverage• Cisapride: drug interaction
ANTIEMETICS
• Phenergan: tablets, suspension, suppository, cream
• Zofran/Kytril: ODT, pill, patch• Marinol• Benadryl• Scopolamine • Ginger• Acupuncture
TUBE FEEDING
• Radiologic GJ tube• Endoscopic GJ tube• Surgical J tube• Venting gastrostomy optional• Temporary: gastric function may return after
several months of enteral nutrition
TPN
• Temporary measure• Enteral feeding effective in most patients• Infection• Thrombosis
GASTRIC ELECTRICAL STIMULATION
• How does it work?• Effective for nausea and vomiting• Does not “pace” stomach• May, or may not, accelerate gastric emptying• Lag phase: may take 6 months to work
GES SURGERY
• Laparoscopy• Risk of infection• Electrode migration• Warning: No MRI• FDA approved: not experimental• Insurance issues
RATIONALE FOR GASTRIC ELECTRICAL STIMULATION
• Cardiac pacing effective for some dysrhythmic disorders
• Stomach also has a “pacemaker” rhythm• Gastric “dysrhythmias” identified• Smooth muscle “pacemakers” identified in
small intestine, colon, ureter, bladder, uterus
Background
• ECA: electrical control activity; 3 cpm in humans, 5 cpm in dogs
• ERA: electrical response activity, ie gastric contractions
• GES entrains electrical activity in man and dogs
• Unclear whether GES can generate muscular contractions
Gastric Electrical Stimulation for Medically Refractory Gastroparesis
THOMAS ABELL, RICHARD McCALLUM, MICHAEL HOCKING, KENNETH KOCH, HASSE ABRAHAMSSON, ISABELLE LEBLANC, GREGER LINDBERG, JAN KONTUREK, THOMAS NOWAK, EAMMON M. M. QUIGLEY, GERVAIS TOUGAS, AND WARREN STARKEBAUM.
University of Mississippi, Jackson, Mississippi; University of Kansas, Kansas City, Kansas; University of Florida, Gainesville, Florida; Penn State University, Hershey, Pennsylvania; University of Goteborg, Sweden; Hospital Charles Nicolle, Rouen, France; Karolinska Institute, Stockholm, Sweden; Elbe Kliniken Stade, Stade, Germany; St.Vincent Hospital, Indianapolis, Indiana; National University of Ireland, Cork, Ireland; McMaster University, Hamilton, Ontario, Canada; and Medtronic, Inc., Minneapois, Minnesota.
GASTROENTEROLOGY 2003; 125: 421-428
EFFICACY OF GES
• Diabetic gastroparesis: 80-90%• Idiopathic: 70%• Postoperative: 60%
EFFECT OF GASTRIC STIMULATION ON CEREBRAL BLOOD FLOW IN
PATIENTS WITH GASTROPARESIS
Thomas V. Nowak1, Gary Hutchins2, Joel Hammond1, Yang Wang2,
Lyn Ring1 and Kativa Leal1
1Department of Medicine, St.Vincent Hospital, Indianapolis, Indiana, USA and
2 Department of Radiology, Indiana University Medical Center,Indianapolis, Indiana, USA.
PURPOSE
To determine whether GES produces changes in regional cerebral blood flow using positron emission tomography (PET).
CONCLUSIONS
• Gastric electrical stimulation of the stomach in gastroparetic patients produces significant alterations
in cerebral blood flow.
• Gastric electrical stimulation both increases and decreases blood flow to respective regions of the
brain.
• Central nervous system mechanisms during gastric electrical stimulation may be responsible for the
relief of nausea and vomiting in these patients.
GES: Issues Remain
• Mechanism: How does it work?• Which patients are best candidates for GES?• Optimal stimulus parameters• How to monitor treatment• Electrode placement: serosa, mucosa, fundus,
vagus nerve?• What about symptomatic patients with
normal or fast gastric emptying?
GES COLLABORATION
IU GASTROENTEROLOGY/HEPATOLOGY
PURDUE BIOMEDICAL/ELECTRICAL ENGINEERING
19 Aug 2013
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[1] M.P. Ward et al. (In preparation - 2013). “A flexible closed-loop platform for rapid biofeedback control and personalization of electroceutical therapies.” [2] Richard M. Peek, Jr & Martin J. Blaser. (2002). “Helicobacter pylori and gastrointestinal tract adenocarcinomas.” Nature Reviews Cancer 2, pp. 28-37.
Experimental Setup
[2]
[1]
Diaphragm
Record VN Response
Stimulate Antrum
Record SM Response
[1]
Cutaneous Recordings of Vagal Afferents
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Current and Future Directions
Finalize research objectives and submit proposals for funding
Biomarker discovery– Directly measure and characterize smooth muscle response– Multi-electrode recordings (ECoG electrodes)
fMRI studies– Purdue: Rodents– IUSM: GES patients
Investigate VNS as an alternative to GES
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