Diabetic Gastroparesis is a form of gastric paralysis that results in chronic symptoms from delayed gastric emptying without mechanical obstruction. Common symptoms include nausea, vomiting, bloating, early satiety, and abdominal pain. Gastroparesis is diagnosed by demonstrating delayed gastric emptying through tests like scintigraphy in symptomatic individuals after excluding other causes. Treatment involves nutrition therapy, glycemic control, prokinetic agents, antiemetics, and other modalities like botulinum toxin injection or gastric electrical stimulation.

1. Diabetic Gastroparesis
Ali Djumhana
Div. Gastroenterology dan Hepatologi
Bagian Ilmu Penyakit Dalam RS Hasan Sadikin – FK Unpad
Bandung

2. Gastroparesis
 Gastroparesis is a form of gastric paralysis ;chronic symptoms may
result from abnormal gastric motility associated with delayed
gastric emptying in the absence of mechanical outlet obstruction.
 The symptoms that suggest gastroparesis are variable include
nausea, vomiting, abdominal bloating, early satiety , and
abdominal pain or discomfort
 The symptoms may mimic structural disorders
(PUD,intestinalobstruction,pancreatobliary disorders) and there
also overlap between symptoms of gastroparesis and FD
 Relationship of symptoms to gastric motor function is poor
Parkman HP ( 2004); Park MI(2006)

3. Etiology of Gastroparesis
28%
8%
29%
14%
10%
4%
4% 3%
Idiopathic
Postviral
Diabetic
Postsurgical
Parkinsons
Pseudoobstruction
Scleroderma
Miscellaneous
Soykan I et al. (1998)

4. Epidemiology
 Female > Male (~ 4:1)
 Delayed gastric emptying were found :
– 20 - 40 % of pts with F D
– 26 - 68% % of pts with Diabetes
 Incidence of delayed gastric emptying:
– 4.5% DM 1
– 1% DM 2
– 0.1% Non DM

5. Physiology of Gastric motility

6. =Parasympatetic ( N Vagus)
=Sympatetic
=Enteric neural system
=Neurotransmitter
(Acetylcholine,dopamin,
serotonin)
=Hormone ( glucose regulating
hormone)
=Food composition
(fat,CHO,solid,fluid)
Regulation of gastric motility

7. Physiology of gastric motility
Motor function of stomach is controlled at three
main levels
 Autonomic nervous system
 Enteric neuronal system
 Interstitial Cell of Cajal
 Smooth muscle cell
Several subsystems are involved:
 afferent receptors
 neurohumoral substances
 circulating hormones
ICCs
ICCs

8. Motility of the gut
excitation
inhibition

9. Physiology of gastric emptying
Gastric emptying results of :
 Tonic contraction of the fundus,
 Phasic contraction of the antrum,
 Inhibitory forces of pyloric and duodenal
contraction

11. Pathophysiology Diabetic gastropsresis
Gut 2010;59:1716-1726

12. Pathophysiology Diabetic gastroparesis

13. Pathophysiology of Gastroparesis
Abnormal gastric motility
 Abnormal gastric accommodation
 Gastric dysrhythmias
 Antral hypomotility

14. Evaluation of patients suspected
gastroparesis
 Gastroparesis is diagnosed by demonstrating
delayed gastric emptying in a symptomatic
individual after exclusion of other etiologies of
symptoms
 Gastroparesis is often suspected in patient
subgroup with specific profile
 DM
 After vagotomy
 FD
 GERD
Parkman HP ( 2004); Rayner CK (2005)
Park MI(2006)

15. Evaluation of patients suspected
gastroparesis
 HT and PE
 Laboratory testing
 Evaluation for organic disorders
 Evaluation for delayed gastric emptying
 Evaluation of response to treatment trial
 Further evaluation

16. History taking and Physical Examination
 HT
 Differentiated of vomiting from regurgitation and ruminating
 Risk factors
 Poor glycaemic controlled
 Female
 History of medication (GLP-1 agonist/receptor analogue,etc)
 PE
 Hydration status
 Nutrition status
 Succussion splash

17. Diagnosis
Gut 2010;59:1716-1726

18. Evaluation of patients
Suspected Gastroparesis

19. Test to assess gastric motor and myoelectrical function
 Assessing gastric emptying
 Upper Ba radiography study
 Scintigraphy
 USG
 MRI
 Breath test
 Assessing gastric contractility
 Antroduodenal manometri
 Gastric barostat
 Satiety test
 Assessing electrical activity
 EGG

20. Treatment of symptomatic
gastroparesis
 Nutrition teraphy
– Hydration and corection of electrolite imbalance
– Liquid or parenteral nutrition
– Micronutrient
– Vitamins ( Cobalamin,vitamin C, etc)
 To tighten glicaemic control
 Prokinetic agents
 Anti emetic agents
 Others modality
– Botulinum injection
– Gastric electrical stimulation
– Gastrostomy and jejunostomy placement
– Surgical treatment

21. Treatment of symptomatic
gastroparesis
 Dietary modification
– Liquid diet is recommended to patient with
gastroparesis who have delayed solid emptying
– Frequent (4 – 5 x daily) and small size diet
– Minimized fat and fiber intake
– Avoid alcohol and carbonated beverages
 To tighten glicaemic control.

22. Treatment of symptomatic gastroparesis
Medical treatment
 Prokinetic agent
– Dopaminergic agent
 Dopaminergic antagonist
– Metoclopramide
– Domperidone
– Mosapride
– Serotonergic agent
 5HT4 agonist
– Pucalopride
– Cisapride
– Tegaserod
 5HT3 antagonist
– Ondansetron,granisetron
– Motilin agonist
 Eritromycin
 Antiemetic agent
– Phenotiazine
 Psychotropic
– Benzodiazepin
– Antidepresant

23.  New and other agents
 Motilides
– Mitemcinal
– ABT 229
 CCK antagonist
– Loxiglumide
 NO donors
– Sidenafil ?
 Ghrelin
 5 HT1 agonist
– Sumatriptan
– Buspiron
Treatment of symptomatic
gastroparesis

24. Commonly used prokinetic drugs
Rayner CK and Horowitz M (2005) New management approaches for gastroparesis
Nat Clin Pract Gastroenterol Hepatol 2: 454–462 doi:10.1038/ncpgasthep0283

25. Treatment of symptomatic gastroparesis
Others therapeutic modalities
 Endoscopic treatment
– Botulinum toxin injection
 Gastric electric stimulation
 Gastrostomy and jejunostomy placement
 Ginger, Acupuncture
 Surgical treatment

26. Improvement
Presumptive diagnosis of gastroparesis
Assessment of patients to rule out mechanical obstruction or another diseases
Nutrition;glycaemic control
Empiric trial of prokinetic for 4-8 wks
History of symptoms gastroparesis
No improvement
Treatment continue
And Pulse Tx
Perform UG-Endos/ Ba meal
Negative finding Structural lesion
Appropriate Tx
High dose
medical Tx
Test Gastric emptying
Improvement No Improvement
Abnormal Normal
High dose prokinetic
Or other modalities
Re-evaluate the D/
Improvement

27. Conclusion (1)
 Gastroparesis is a syndrome characterized
by delayed gastric emptying in the
absence of mechanical obstruction
 Diabetic gastroparesis is the main cause of
gastroparesis
 Scintigraphy is a gold-standard for
diagnosis

28. Conclusion (2)
 Patients with presumptive diagnosis
gastroparesis should be cared for empirical /
trial treatment.
 The treatment include ;Nutrition teraphy
(Macro and micro nutrient,vitamins
etc), metabolic control and prokinetic agent
 Novel treatment including new
prokinetics, botulinum toxin injection,gastric
electrical stimulation have been tested in
patients with gastroparesis