Post surgical gastroparesis

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Gastroparesis after surgery is a common clinical entity

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Post surgical gastroparesis

  1. 1. History • • • • • 4th Post op day Nausea + Vomiting:3episodes Abdomen distended Not passed flatus or motion
  2. 2. Post Surgical Gastroparesis Presenter-Dr.Amit Goswami
  3. 3. Introduction • Post prandial nausea and vomiting and gastric atony without mechanical obstruction • Pathogenesis not well explained • Definition varies
  4. 4. Gastric pacesetter potentials or slow waves Cutaneous 3cmp EGG waves Fundus Peristalti c wave Corpus 3 cpm slow waves plus action potentials
  5. 5. Etiology of Gastroparesis
  6. 6. Clinical Manifestations • • • • Nausea Vomiting Bloating Early Satiety 92% 84% 75% 60%
  7. 7. Gastroparesis Cardinal Symptom Index (GCSI) • Each parameter scored on 0-5 scale 1. Nausea 2. Retching 3. Vomiting 4. Stomach Fullness 5. Not able to finish normal-sized meal 6. Feeling excessively full after meals 7. Loss of appetite 8. Bloating (feeling like you need to loosen your clothes) 9.Stomach or belly visibly larger
  8. 8. Grade
  9. 9. Post Surgical Gastroparesis
  10. 10. Incidence • Peptic ulcer surgery with vagotomy • Gastrectomy(0.4%-5%) • Pancreatoduodenectomy(20-50%) • Pancreatic cancer cryoablation(50-70%) • Heart and lung transplantation
  11. 11. ISGPS suggested definition
  12. 12. • Absence of mechanical gastric outlet obstruction • Gastric juice aspirate >800ml for more than 10 days • No abnormalities in water, salt, electrolytes, or acid–alkali balance • Absence of underlying diseases • No history of using suggestive agents
  13. 13. Pathogenesis-Surgical factors • Multifactorial • Denervation and resulting atony in gastric remnant (Frederic et al.) • Effect of vagotomy in proximal and distal stomach • Loss of vagal suppression on ectopic intestinal pacemaker • Associated procedures
  14. 14. Neuroendocrine and molecular factors • Hyperglycemia • Autonomic neuropathy • Surgical stress-catecholamines • Low motilin(absence of duodenum) • Damage to ICC • Hypothyrodism
  15. 15. Evaluation • History • Abdominal distention, Succussion splash • Clues to other etiologies • Lab Tests
  16. 16. Evaluation • EGD or Barium study – Rule out gastric outlet obstruction
  17. 17. Evaluation • Gastric Scintigraphy – Gold standard – 99M Tc Sulfur colloid bound to solid food – Lack of standard criteria between institutions • T1/2 or time intervals • Different diagnostic criteria determined at each institution – Delay of 2 SD vs. 1.5 SD vs. 1 SD • Different Meals • Different patient positions
  18. 18. Gastric scintigraphy Wu D J Y et al. BMJ Case Reports 2009;2009:bcr.06.2009.1986 ©2009 by BMJ Publishing Group Ltd
  19. 19. Problems with Scintigraphy • Radiation exposure • Expensive • Lack of standardization – – – – differences in meals used patient positioning frequency and duration of imaging Differences in quantitative data reported • T1/2, rate of emptying, retention at different time points • Lack of normal values
  20. 20. Wireless Motility capsule
  21. 21. WMC 1. Gastric emptying time 2. Small bowel transit time 3. Colonic transit time 4. Whole gut transit time 5. Amplitude of distal antral and duodenojejunal contractions 6. Amplitude of phasic contractions of colon 7. Intragastric acidity
  22. 22. Breath test • 13C-labelled octanoate incorporated in a solid meal • Metabolised to 13C02 • 13C-spirulina
  23. 23. Complementary modalities • Antroduodenal Manometry • Electrogastrography
  24. 24. Treatment • Correct fluid, electrolyte, and nutritional deficiencies; • Identify and rectify the underlying cause of gastroparesis; • Reduce symptoms-Ryle’s tube
  25. 25. Dietary Recommendation • Increasing liquid nutrient content of the meal • Minimized fats and fiber intake • Restricted meal size • Alcohol to be avoided
  26. 26. Prokinetic Agents • Enhance antral contractility • Correct gastric dysrhythmias • Improve antroduodenal coordination
  27. 27. Metoclopramide • Antiemetic effect: D2,5-HT3 antagonism • Prokinetic effect: +Ach release • 5-HT4 receptor agonist – Increase LES pressure/fundic tone – Increase antral contractions
  28. 28. • Prokinetic effect limited to proximal GIT • Effective for short term treatment • Parenteral form available • Nine trials Pa rkman HP, Ha s l e r WL, F i s h e r RS . Ame r i c a n Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology 2004; 127: 1592-1622
  29. 29. Erythromycin • Gastroduodenal receptors of motilin • + Antral contractility, Premature phase III MMC • Parenteral-most effective • Narrow therapeutic window
  30. 30. Domperidone – Benzimidazole derivative – Dopamine 2 antagonist – Promotility effect in upper GI tract – Doesn’t cross blood-brain barrier • Fewer central side effects – Hyperprolactimemia, breast engorgement, galactorrhea
  31. 31. Levosulpiride • Selective D2 blocker, moderate 5HT4 agonist • Superior than placebo • Superior to Domperidone and Metoclopramide in functional dyspepsia Mansi C, Savarino V, Vigneri S, et al. Gastrokinetic effects of levosulpiride in dyspeptic patients with diabetic gastroparesis.Am J Gastroenterol 1995; 90: 1989±93.
  32. 32. Antiemetic Agents • May be needed for additional nausea relief • Role in gastroparesis not well established
  33. 33. Botulinum Toxin • Intrapyloric injection Gastric emptying(decreased release of excitatory transmitter) • No controlled study
  34. 34. Refractory Gastroparesis • Combination therapy • Gastrostomy/Jejunostomy • Gastric electric stimulation Potentiate intrinsic slow waves and phase III contractions
  35. 35. Surgical options • In retractable cases as last resort • Subtotal or completion gastrectomy • Small uncontrolled series • Forstner-Barthell et al: Largest series  60 patients  40 symptomatic improvements • No definite winner
  36. 36. Take Home Message
  37. 37. • Etiology and pathogenesis not well explained • Diet and lifestyle alterations, prokinetics and anti-nausea medications are the mainstay of therapy • Novel medications and device are currently being studied and offer promise • Evidence based investigation required

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