Gastroparesis

Abeezar I. Sarela Consultant in Upper GI & Bariatric Surgery Hinduja Hospital, Mumbai St James’s University Hospital, Leeds, UK Gastric Motility Disorders

Case Study
52 year old woman
Fullness after a small meal
Continuous nausea
6-8 episodes of vomiting daily
Upper abdominal bloating
Diabetes
Insulin, Metformin, Exenatide

Endoscopy Barium Meal and Follow-Through CT scan

Functional Dyspepsia?

Gastroparesis
Delayed gastric emptying in the absence of mechanical obstruction of the stomach

True Prevalence?
25-40%
of “dyspeptic” patients
American Gastroenterological Association Technical Review on the Diagnosis and Treatment of Gastroparesis. Gastroenterology 2004;127:1592-1622

Aetiology of Gastroparesis
Idiopathic
Diabetes mellitus
Post-surgical
Partial gastric resection/vagotomy
Bariatric surgery
Anti-reflux surgery
Associated with other GI disorders
Associated with Non-GI disorders
American Gastroenterological Association Technical Review on the Diagnosis and Treatment of Gastroparesis. Gastroenterology 2004;127:1592-1622

Diabetic Gastroparesis
5-12% of diabetics
Long duration of disease ~ 10 years
Neuropathy, nephropathy, retinopathy

Diabetic Gastroparesis
Destabilisation of blood glucose control
Alteration in drug absorption
Unpredictable delivery of food into intestine
Hyperglycemia affects gastric motility
Problems with blood glucose control may be first indication of gastroparesis

Diagnosis Nuclear Medicine Gastric Scintigraphy

Normal Liquid Emptying from Stomach Exponential Curve ~ Measure T½

Normal Emptying of Solid Food from Stomach

Normal Emptying of Solid Food from Stomach Linear Pattern ~ Measure Proportion Retained in Stomach At 1 hours and 4 hours

Measuring Gastric Emptying Dual Phase Scintigraphy
Scintigraphy uses different radionuclides for labeling the liquid and solid elements of the meal so that emptying curves for both phases are obtained simultaneously

Normal Gastric Emptying

N ormal Pattern
Liquid phase
T½ less < 30 minutes
Solid phase
at least 25% of the meal leaves the stomach by 60 minutes
<15% is retained in the stomach at 4 hours

Gastroparesis solid liquid

liquid solid Gastroparesis

Gastric Emptying N Eng J Med 2007; 356:820-829

Other Tests
13 C Labelled Octanoate Breath Test
Antroduodenal Manometry
Electrogastrography
Ultrasound
Magnetic Resonance Imaging

Why is Scintigraphy the Investigation of Choice?
Simple
Non-invasive
Very small radio-active dose
Physiological
Prolonged observation
Quantifiable

Severity of Gastroparesis N Eng J Med 2007;356:820-829 Yes No No Non-pharmacologic treatment Jejunal tube By mouth Rare Nutritional supplements Routine Sometime Rare Homogenised food >35% 16-35% 10-15% Retention at 4 hours Severe Moderate Mild

Treatment of Gastroparesis

1. Correction of Exacerbating Factors

2. Nutrition Homogenised Diet Jejunal Tube Feeding

3. Symptomatic Treatment
Macrolides
Erythromycin
Dopamine Receptor Antagonists
Metoclorpromide
Erythromycin
Anti-emetics
Analgesia

3. Symptomatic Treatment
Botox injection at pylorus
Surgery
Gastric Electrical Stimulation

Gastric Smooth Muscle Function
Gastric slow waves (Phasic): 3/min
Bradygastria, Tachygastria, Gastric Dysrhythmia
Tonic spikes superimposed on slow waves result in smooth muscle contraction
Soffer et al. Aliment Pharmacol Ther 2009;30:681-694

Gastric Electrical Stimulation (GES)
Gastric Pacing:
Entrain slow waves
Low-frequency + Long duration
Implantable Pulse Generator (IPG) not available
Implantable GES
High frequency + Short duration
Slow waves not altered
Neural stimulation
Clinically Used GES is NOT pacing

Enterra ™ Therapy (Medtronics) for Gastroparesis
Humanitarian Device Exemption approval from the US FDA in 2000
Handheld, external programmer to adjust the neurostimulator and customize therapy
Therapy can be turned off at any time

Electrophysiology of Enterra ™ Therapy
High-Frequency stimulation with
trains of
Short-Duration pulses
Soffer et al. Aliment Pharmacol Ther 2009;30:681-694

Enterra ™: Position of Electrodes 9 cm 10 cm 1 cm

Implantation of Enterra ™ Electrodes

Enterra ™ Therapy
~ 1000 devices used world-wide
Largest experience:
University of Mississippi Medical Centre, Jackson, USA
~ 600 cases
UK
8 regional centres

Improvement in one of three parameters: 90%
Health Related Quality of Life Score
Improved to 16.3 from 10.6
Vomiting Frequency Score
Decreased to 1.9 [0.1] from 2.9 [0.1]
Total GI Symptom Score
Decreased to 10.9 [0.2] from 15.6 [0.3]
Gastric Emptying
Two-hour retention fell from 55% to 42%
Four-hour retention fell from 26% to 17%
Results of Enterra™ Therapy 214 patients. 1992-2005. Univ. of Miss Med Ctr. Anand et al. Digestion 2007;75:83-89

Predictors of Poor Outcome
Predominant symptoms: pain and bloating
Idiopathic gastroparesis
Loss of interstitial cells of Cahal on full thickness gastric biopsy
Electrogastrogram: tachygastric rhythm

Endoscopy-Placed, Trans-Nasal Electrodes: Evaluation of Response to Temporary Therapy

Gastroparesis
Commoner than we think
Radio-labelled scintigraphy
Optimise diabetes treatment
Nutrition
Symptom-control
Enterra ™

Controversies
Quality of evidence: Weak
Only one RCT – poor
Variable scoring systems
Attrition bias
Confounded by concurrent pharmacotherapy
Relationship between delayed emptying and symptoms is unclear
Mechanism of action is unclear

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Gastroparesis

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