Presentation Gastroparesis

8/10/2019 Presentation Gastroparesis

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Bronx VA Longitudinal Clerkship 2014

Treatment of RefractoryGastroparesisSunjay Barton MS3




Case

• 49-year-old man with history of poorly controlleddiabetes and multiple hospitalizations for acute

exacerbations of gastroparesis

• Diagnosed with gastric scintigraphy, wireless

motility capsule

• Recurrent nausea, vomiting, severe crampy

abdominal pain




Failed medical treatments: diet modification

• Avoid fat (slows gastric emptying) and insolublefiber

• Small, frequent meals

• Blend food (liquid = rapid transit)

• Avoid alcohol/smoking (decreases motility)

• Optimize glycemic control



Failed medical treatments: metoclopramide

• Patient developed legtwitching concerning

for extrapyramidal

symptoms vs tardive

dyskinesia





Failed medical treatments: erythromycin

• Patient developed side effects of muscleweakness and blurred vision

• Patient discontinued medication after one week

• Interaction with statins (rhabdomyolysis, AKI)




Additional medical treatment options

• Domperidone (D2 antagonist; difficult to obtain inUS)

• Azithromycin

• Cisapride (5HT4 agonist; difficult to obtain in US)

• Anti-emetics: diphenhydramine, ondansetron,

prochlorperazine, TCAs

• Scopolamine, aprepitant, dronabinol have beenused, but no evidence for effectiveness




Previous surgical treatment: Botox pyloroplasty

• Temporarily relieved patient’s symptoms • No benefit in RCTs

• Not recommended in American College of

Gastroenterology guidelines for management ofgastroparesis [1]






Additional treatments: G tube / J tube

• Gastrostomy tube placement for decompression• Jejunostomy tube placement for feeding in patients

with significant weight loss

• G tube +/- J tube reduced number ofhospitalizations 5-fold in prospective trial of 22

patients [3]



Gastric electrical stimulation: hardware

• Battery pack implantedin abdominal wall

• Electrodes deliver low

energy electrical

stimulation to stomach

at 12 cycles per

minute

• Physiologicoscillations are 3 cpm





Gastric electrical stimulation: evidence

• Humanitarian device exemption for refractorydiabetic or idiopathic gastroparesis

• Double-blind, randomized crossover study of 33

patients in 2003 demonstrated reduction of weekly

vomiting frequency and improvement in quality of

life [4]

• Significant improvement seen in diabetic subgroup

as well as whole cohort




Gastric electrical stimulation: mechanism

• Unclear• No effect on gastric emptying

• Increases maximal tolerated gastric distention

• Research continues on devices that deliver

physiologic low frequency gastric pacing, currently

too large for implantation



Summary





Sources

1. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical

guideline: management of gastroparesis. The American journal ofgastroenterology. 2013;108:18-37.

2. Hibbard ML, Dunst CM, Swanstrom LL. Laparoscopic and

endoscopic pyloroplasty for gastroparesis results in sustained symptom

improvement. Journal of gastrointestinal surgery: official journal of the

Society for Surgery of the Alimentary Tract. 2011;15:1513-9.

3. Borrazzo EC. Surgical management of gastroparesis:

gastrostomy/jejunostomy tubes, gastrectomy, pyloroplasty, gastric electrical

stimulation. Journal of gastrointestinal surgery: official journal of the Society

for Surgery of the Alimentary Tract. 2013;17:1559-61.4. Abell T, McCallum R, Hocking M, et al. Gastric electrical stimulation

for medically refractory gastroparesis. Gastroenterology. 2003;125:421-8.

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Presentation Gastroparesis