The upper gastrointestinal tract, common conditions, and recommended treatments
Simon R. Knowles, Laurie Keefer, Antonina A. Mikocka-Walus in Psychogastroenterology for Adults, 2019
Gastroparesis is an uncommon condition characterised by delayed stomach emptying and may be due to medical conditions such as diabetes or previous surgery or may be idiopathic (no specific underlying cause found). The prevalence varies worldwide according to the causes; up to 40% of patients with diabetes have delayed emptying but only a minority of those have troublesome symptoms. Typical symptoms include nausea and vomiting (often of food eaten some time before, even the previous day), upper abdominal discomfort, bloating, and pain. The condition may be diagnosed at endoscopy if the stomach is discovered to be full of food, or on a stomach-emptying study. The degree of delay in gastric emptying correlates only poorly with the severity of symptoms and there are likely to be other factors contributing to symptoms, particularly in patients with idiopathic gastroparesis. Issues in the management of patients with gastroparesis include control of symptoms and maintaining nutrition. Initial steps focus on dietary modification, with more frequent, smaller meals; texture modification to a soft diet that is easily broken down and processed by the stomach; and avoidance of foods such as fatty or fibrous foods that increase symptoms or empty more slowly from the stomach. Patients may require liquid nutritional supplements as liquids generally empty better from the stomach than solids. If these modifications are insufficient to provide adequate nutrition, supplemental feeding via a tube placed into the small bowel may be required. Nausea is managed with medications that speed gastric emptying and other antiemetics (medications that reduce nausea/vomiting), gastrooesophageal reflux symptoms are managed with acid suppression, and pain is managed using non-narcotic analgesics. In patients with refractory symptoms, endoscopic or surgical interventions to reduce resistance to stomach emptying at the pylorus (the muscle controlling the outlet of the stomach) such as injection of botulinum toxin or surgical/endoscopic pyloromyotomy (cutting of the pylorus), or gastric electrical stimulation may be considered, although results of these procedures are variable and good outcomes are not assured.
Diabetes
Awanish Kumar, Ashwini Kumar in Diabetes, 2020
In 1958, Kassender coined the term ‘gastroparesis diabeticorum’ for the symptom of delayed gastric emptying in diabetic patients. Gastroparesis is a pathological condition where there is delayed gastric emptying without any mechanical or pharmacological inhibition. The classical symptoms of gastroparesis are a sense of early fullness during eating (early satiety), feeling of fullness even long after having a meal which is often accompanied by bloating, nausea and vomiting. Diabetes is considered as one of the major causes with almost one-third of gastroparesis patients being diabetic. Other causes could be gastrointestinal surgery or a neurological problem. Gastroparesis is a chronic complication of diabetes and mostly, such gastroparetic patients also have other diabetes-related complications such as retinopathy and neuropathy. Diabetic patients show gastroparesis primarily due to neuropathy that affects the vagus nerve, and reduction in the number of gastric pacemaker cells (interstitial cells of Cajal or ICC). This neuropathy complication is a part of a larger neuropathy conglomeration known as diabetic autonomic neuropathy (DAN). The gastroparetic symptoms can become worse in diabetic patients taking certain medications such as amylin analogue (Pramlintide) or GLP-1 analogues (e.g. Exenatide). Specifically, diabetes-related gastric symptoms could be divided into oesophageal dysmotility, gastroparesis and diabetic enteropathies (intestinal dysmotility, diarrhoea and faecal incontinence). The American College of Gastroenterology (ACG) suggests that a combination of suitable symptoms along with delayed gastric emptying without any mechanical or pharmacological interventions is essential to diagnose diabetic gastroparesis [58,59]. The techniques which are commonly applied to diagnose diabetic gastroparesis are gastric scintigraphy, ultrasonography, magnetic resonance imaging (MRI), single-photon emission computed tomography, electrogastrography (EGG) and wireless motility capsule (smart pill). While the management of gastroparesis includes diet and lifestyle management, diabetic patients suffering from gastroparesis must manage their diabetes through pharmacological treatment as suggested by a physician.
Motility disorders
Michael JG Farthing, Anne B Ballinger in Drug Therapy for Gastrointestinal and Liver Diseases, 2019
The first line of therapy in patients with gastroparesis is dietary modification and treatment of any underlying condition. Patients should be instructed to eat frequent, small meals throughout the day. Meals should be low in fat and fibre since both these components will delay gastric emptying. Since liquids exit the stomach quicker than solids, liquid or puréed foods are recommended. Several agents are available that enhance gastric emptying; however, comparative studies between these treatments are rare. In practical terms, these agents should be tried for 1 month to assess efficacy and acceptability. Ideally, formal documentation of emptying with scintigraphy should be tried, although the correlation between symptoms and documented gastroparesis is poor. Metoclopramide has been demonstrated to improve gastric emptying in patients with gastroparesis; however, results have been inconsistent. Cisapride has been demonstrated in a variety of studies to improve objective measurements of gastric emptying and symptoms in patients with gastroparesis. In other studies, the effects on symptoms has been less impressive. Erythromycin has been shown to improve gastric emptying in patients with diabetic gastroparesis.
Emerging strategies for the treatment of gastroparesis
Published in Expert Review of Gastroenterology & Hepatology, 2016
James Langworthy, Henry P Parkman, Ron Schey
Gastroparesis is a syndrome of delayed gastric emptying in the absence of mechanical obstruction. Symptoms can be debilitating, affect nutritional states, and significantly impact patients’ quality of life. The management of these patients can prove quite difficult to many providers. This article will review the current management recommendations of gastroparesis, discuss investigational medications and interventions, and summarize future directions of therapies targeting the underlying disease process. Current therapies are subdivided into those improving gastric motility and those directly targeting symptoms. Non-pharmacologic interventions, including gastric stimulator implantation and intra-pyloric botulinum toxic injection are reviewed. A discussion of expert opinion in the field, a look into the future of gastroparesis management, and a key point summary conclude the article.
Gastroparesis managed with peroral endoscopic pyloromyotomy
Published in Baylor University Medical Center Proceedings, 2020
Jessica S. Clothier, Steven G. Leeds, Ahmed Ebrahim, Marc A. Ward
Gastroparesis is delayed gastric emptying in the absence of mechanical obstruction. Cases are attributed to narcotic use, smoking, diabetes, and postsurgical complications; however, several incidences are unknown. Treatment options include diet modification, gut-stimulating medications (e.g., metoclopramide, domperidone), laparoscopic pyloroplasty, and, in the most severe cases, partial gastrectomy with Roux-en-Y reconstruction. Recently, a novel therapy has been developed, peroral endoscopic pyloromyotomy (POP). This procedure is similar to a laparoscopic pyloroplasty; however, it is performed completely endoscopically, thus negating the need for incisions. Here we present a case of gastroparesis treated with this novel technique.
Metoclopramide in the treatment of diabetic gastroparesis
Published in Expert Review of Endocrinology & Metabolism, 2010
Gastroparesis is a chronic disorder that affects a significant subset of the population. Diabetes mellitus is a risk factor for the development of gastroparesis. Currently, metoclopramide is the only US FDA-approved medication for the treatment of gastroparesis. However, the FDA recently placed a black-box warning on metoclopramide because of the risk of related side effects, including tardive dyskinesia, the incidence of which has been cited to be as high as 15% in the literature. This review will investigate the mechanisms by which metoclopramide improves the symptoms of gastroparesis and will focus on the evidence of clinical efficacy supporting metoclopramide use in gastroparesis. Finally, we seek to document the true complication risk from metoclopramide, especially tardive dyskinesia, by reviewing the available evidence in the literature. Potential strategies to mitigate the risk of complications from metoclopramide will also be discussed.
Related Knowledge Centers
- Paralysis
- Small Intestine
- Diabetes Mellitus
- Stomach
- Stomach Diseases
- Paresis
- Vagus Nerve