Gastric motor sensory disorders

1. AJG Dec21
Kurdistan Board GEH/GIT Surgery J Club 2021
Supervised by Professor Dr. Mohamed Alshekhani.

2. Introduction:
 Gastric sensorimotor conditions are highly prevalent disorders that
significantly affect patients’ QOL& negatively impact the health care
system.
 A series of clinically focused questions can be used to help identify &
distinguish these chronic disorders.
 Empiric therapy can be initiated for many of these disorders (e.g.,
rumination syndrome, FD) based on symptoms, a normal physical
examination&the absence of warning signs.
 When necessary, diagnostic testing should be performed in a logical, step-
wise manner, with the underlying premise that test results should guide
therapeutic management.
 Accurately measuring gastric emptying helps distinguish gastroparesis
from other disorders (FD, CNVS, CVS, CHS) which may help to guide
appropriate therapy.

3. Introduction:
 For some, preparing & eating food provides immense satisfaction.
 For others, eating causes significant distress&generate a range of
sensations highlights the fact that the stomach is an extraordinarily
complex sensorimotor organ.
 Tirelessly, subconsciously&usually without complaint, the stomach
performs 3 key functions: accommodating ingested food; triturating
gastric contents; emptying liquids & small grounded food into duodenum.
 These functions generally occur without causing distress; but a significant
portion of the population suffers from meal-related symptoms.
 Typical symptoms develop due to abns in gastric sensorimotor function
include epigastric pain, burning, pressure or fullness, nausea, vomiting,
early satiation, bloating&belching.
 These symptoms are non-specific, potentially represent any number of GI
organic, functional or motility disorders,for example, early satiation is a
cardinal symptom of functional dyspepsia (FD), although it is also
commonly reported by patients with gastroparesis (GP).

4. Introduction:
 FD is much more common than gastroparesis with a prevalence of 7-10%,
vs 0.01%-1.8% with GP
 Symptoms of nausea / vomiting are common in patients with GP; however,
they are also present in cyclic vomiting syndrome (CVS), cannabinoid
hyperemesis syndrome (CHS)&chronic nausea/vomiting syndrome
(CNVS), with a combined estimated prevalence rate of 2% for the latter 3
disorders.
 These disorders cause a significant negative impact to the health care
system & dramatically reduce patients’ QOL.
 Unfortunately, FDA treatment options are limited only to metoclopramide
for GP.

6.  Gastric response to ingestion of a meal.
 I. After food is ingested the proximal stomach (fundus&proximal
gastric body) relaxes in order to accommodate a large volume of
food without a significant increase in intragastric pressure(
property of receptive relaxation).
 II. Ingested food is slowly moved from the fundus to the body&
antrum where the process of trituration occurs. Peristaltic wave
mix the ingested food with gastric acid/pepsin& move the food
towards the closed pylorus, which breaks the food up into small
particles, suitable for emptying.
 III. When food particles are of the appropriate size (1-2 mm)&
viscosity, small aliquots are emptied from the antrum into the
duodenal bulb.
 This generally occurs at 3 peristalses/minute. Retropulsion of
larger food particles from the pylorus back to the antrum&body
permits further stomach mixing.

14.  A-C. Diagnostic testing for gastric motor & sensory disorders:
 an algorithmic approach
 A. Treatment needs to be individualized if upper endoscopy is abnormal, but
could include a PPI for gastritis or ulcer disease, or treatment for H pylori, if
present. If upper endoscopy is normal, empiric therapy for nausea & vomiting.
 B.Some providers may consider testing with mesenteric duplex or SPECT or
small bowel imaging prior to performing gastric emptying scintigraphy,
especially if symptoms of nausea &/or vomiting are minimal or absent. Empiric
therapy for the treatment of dyspepsia generally begins with PPI, followed by a
neuromodulator
 C.Recognizing that validated treatment algorithms do not exist, treatment for
belching generally begins with lifestyle changes, dietary changes&behavioral.
 Results of impedance-pH testing may help guide therapy in some patients, while
neuromodulators may help others.
 CHS, cannabinoid hyperemesis syndrome; CNVS, chronic nausea/vomiting
syndrome; CVS, cyclic vomiting syndrome; GES, gastric emptying scintigraphy;
SB, small bowel; SPECT, single photon emission computed tomography;
 US, ultrasound.

19. Conclusion:
 Gastric sensorimotor conditions are highly prevalent disorders that
significantly affect patients’ QOL&negatively impact the health care
system.
 A series of clinically focused questions can be used to help identify and
distinguish these chronic disorders.
 Empiric therapy can be initiated for many of these disorders(e.g.,
rumination syndrome, FD) based on symptoms, a normal physical
examination&the absence of warning signs.
 When necessary, diagnostic testing should be performed in a logical, step-
wise manner, with the underlying premise that test results should guide
therapeutic management.
 Accurately measuring gastric emptying helps distinguish gastroparesis
from other disorders (FD, CNVS, CVS, CHS) which may help to guide
appropriate therapy.

20. CME1:
 A 25-year-old woman is referred by PCP for chronic vomiting,post-
prandial sensation of food effortlessly traveling into her mouth.
 She sometimes rechews&swallows the food. She denies abdominal pain,
nausea, hematochezia,melena, or unintentional weight loss.
 On physical exam,her vital signs are unremarkable, abdomen is soft,
nontender& non-distended without scars. She has no history of prior GI
surgeries. Lab:normal CBC& basic metabolic panel.
 What is the best next step in management of this patient?
 A. Upper endoscopy
 B. Gastric emptying study
 C. Antroduodenal manometry
 D. Esophageal manometry with impedance
 motility capsule

21. CME2:
 A 35-year-old woman who is 6 months post-partum presents with chronic
nausea &vomiting. She reports daily nausea/retching. She also reports
chronic epigastric pain & postprandial fullness &bloating. She notes
unintentional weight loss of 5 lbs. She denies diarrhea, constipation,
hematochezia,melena. She is breastfeeding & regularly pumps. She has a
H/O GDM but takes no medications excepting a prenatal vitamin.
 Vital signs are unremarkable. PE is remarkable for mild epigastric
tenderness to palpation. Lab:CBC, comprehensive metabolic panel, TSH
are unremarkable.OGD with gastric biopsies unremarkable.
 Which of the following diagnostic tests is the most appropriate next step?
 A. 2-hour gastric scintigraphy
 B. 4-hour gastric scintigraphy
 C. Breath test
 D. Single photon emission CT

22. CME3:
 Which of the following diagnostic tests is best to assess gastric
accommodation?
 A. Gastric scintigraphy
 B. Barostat
 C. Endo FLIP
 D. Wireless motility capsule.