Gastroparesis: A ContinuedChallenge

Management of the Complex Hospitalized PatientAugust 14, 2013

Randy P. Wright, MDAssistant Professor

Division of Gastroenterology & Nutrition

Camilleri M, Parkman HP, Shafi MA, Abell TL,Gerson L; American College of Gastroenterology.Clinical guideline: management of gastroparesis.Am J Gastroenterology. 2013 Jan;108(1):18-37

Objectives

Definition Epidemiology & Impact Diagnosis & Differential Management

Pharmacologic Surgical Gastric Electrical Stimulation

Definition

Objective delay in gastric emptying Absence of gastric outlet obstruction or

ulceration Symptoms

Postprandial fullness (early satiety) Nausea Vomiting Bloating MEG abdominal pain

Epidemiology

Prevalence: 24.2/100,000 9.6/100,000 male 37.8/100,000 female

Incidence 1996-2006 2.4/100,000 male 9.8/100,000 female

Epidemiology

Incidence in Olmsted County, MN DM1 4.8% DM2 1% Idiopathic 0.1%

DM gastroparesis Typically develops after DM 10 years Tends to persist despite improved glycemic control More likely to have cardiovascular disease, HTN,

retinopathy

Figure 1 Age-specific incidence of gastroparesis in Olmsted County, Minnesota, 19962006. ( A ) Definite gastroparesis. ( B )Definite plus probable gastroparesis. ( C ) Definite plus probable plus possible gastroparesis. *Comparison of incidence according...HyeKyung Jung , Rok Seon Choung , G. Richard Locke III , Cathy D. Schleck , Alan R. Zinsmeister , Lawrence A. Sza...

The Incidence, Prevalence, and Outcomes of Patients With Gastroparesis in Olmsted County, Minnesota, From 1996 to 2006

Gastroenterology Volume 136, Issue 4 2009 1225 - 1233

http://dx.doi.org/10.1053/j.gastro.2008.12.047

Epidemiology

QOL Hospitalizations have increased since 2000

Poor glycemic control Infection Noncompliance or intolerance of medications

Delayed gastric emptying study predicts: Morbidity Hospitalizations ED and doctor visits

Figure 3 Survival of gastroparesis inception cohort in Olmsted County, 19962006, and expected survival of the sex- and age-matched Minnesota white population in 2000 ( P = .0001). ( A ) Definite gastroparesis. ( B ) Definite plus probable gastroparesis. ...

HyeKyung Jung , Rok Seon Choung , G. Richard Locke III , Cathy D. Schleck , Alan R. Zinsmeister , Lawrence A. Sza...

The Incidence, Prevalence, and Outcomes of Patients With Gastroparesis in Olmsted County, Minnesota, From 1996 to 2006

Gastroenterology Volume 136, Issue 4 2009 1225 - 1233

http://dx.doi.org/10.1053/j.gastro.2008.12.047

Etiology

Idiopathic (IG) 36% DM (DG) 29% Postsurgical (PSG) 13% Parkinsonism Amyloidosis Paraneoplastic syndrome (SCLC, ovarian, etc.) Scleroderma Mesenteric ischemia

Etiology

Extrinsic: Post surgical vagal nerve injury

Fundoplication Peptic ulcer surgery Roux-en-Y bariatric surgery

Roux-en-Y stasis syndrome: Vagotomy predisposes to slowemptying from gastric remnant delayed transit of Rouxalimentary limb

www.hopkinsmedicine.com

Etiology

Extrinsic: Pharmacological blockade

GLP-1 analogs Exenatide (nausea 43% vomiting 12.8%), liraglutide NOT dipeptidyl peptidase IV inhibitors: sitagliptin, saxagliptin,

linagliptin, alogliptin Amylin analogs

pramlintide Narcotics - -opioid agonist

Less so with tramadol Cyclosporine

NOT tacrolimus (prokinetic properties)

Etiology

Enteric & Intrinsic mechanisms Loss of interstitial cells of Cajal (ICC)

pacemaker of the stomach - generate slow waves Loss of neuronal nitric oxide (nNOS)

DM neuropathy oxidative stress loss of ICC and nNOS

Etiology

Post Viral Sudden onset after prodrome illness Usually improves by about a year Autonomic neuropathy (CMV, EBV, VZV)

Slower resolution several years Worse prognosis

Etiology

Delayed gastric emptying longstanding DM1 Rapid gastric emptying early DM2

Vagal dysfunction due to DM or post surgical fundic accommodation gastric pressure rapid emptying of liquids

Figure 1 Pathophysiology of diabetic gastroparesis (Adapted from Gut , Kashyap P, Farrugia G, 2010;59:17161726,with permission from BMJ Publishing Group Ltd).Michael Camilleri , Adil E. Bharucha , Gianrico FarrugiaEpidemiology, Mechanisms, and Management of Diabetic GastroparesisClinical Gastroenterology and Hepatology Volume 9, Issue 1 2011 5 - 12http://dx.doi.org/10.1016/j.cgh.2010.09.022

Diagnosis

Symptomatic Exclusion of other etiologies and obstruction

with endoscopy or radiological imaging Biochemical screen for hypothyroid & DM EGD Enterography or barium UGI

Delayed gastric empting rather thangastroparesis if asymptomatic

Functional Dyspepsia vs.Gastroparesis

Symptom Functional dyspepsia Gastroparesis

Epigastric pain/discomfort 8990 8990

Epigastric fullness 7590

Early satiety 5082 6086Symptoms worsened byeating 79 72

Postprandial fullness 7588

Bloating 6896 5175

Belching 4585

Nausea 6790 9296

Vomiting 2033 6884

Weight loss 58

Lacy BE. Functional dyspepsia and gastroparesis: one disease or two? Am J Gastroenterology. 2012 Nov