Gastroparesis: Inpatient

Management

Canadian Society of Hospital Medicine

IL Epstein, MD, FRCPC

Assistant Professor

Department of Medicine, Dalhousie University

Friday Sept 29, 2017

Disclosures

2017 Ad Board Attendee:

Takeda

Abbvie

No conflicts with any products discussed in

this presentation

Objectives

1. Describe the presentation & symptoms of

gastroparesis in hospitalized patients

2. Demonstrate an approach to diagnosis of

gastroparesis

3. Appraise therapeutic options for

management of complex inpatient

gastroparesis

Case

55 yr old female

PMH Chronic back pain, DM, HTN

Meds: Glyburide, ASA, Ramipril, Metoprolol,

ASA, Hydromorphone

Admitted with UTI, severe nausea

Since admission refractory nausea, frequent

vomiting, abdominal pain

Refractory to anti-emetics; labile sugars;

unable to discharge

Symptoms

Nausea (93%)

Vomiting (68-84%)

Abdominal pain (46-90%)

*rarely the only / predominant symptom

Early satiety (60-86%)

Postprandial fullness, bloating, weight loss

Differential Diagnosis

Functional dyspepsia

Mechanical obstruction

Rumination

CVS

Cannabinoid hyperemesis syndrome

Eating disorder

Pathophsyiology

Often Multifactorial

Gastric “neuropathy”; rarely myopathy

Sensory & motor dysfunction

Vagal injury may be cause, but rare, and not a

factor in all cases

Pathophysiology

https://www.slideshare.net/kaj4/gut-motility-lecture

https://www.slideshare.net/suadboulevardez/chapter-17-gitmod

https://www.slideshare.net/wenyelin/gut-hormone-and-its-implication-in-glucose-homeostasis-11661727

Gastric Emptying

http://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/emptying.html

Causes

3 main categories

Idiopathic (includes neurologic disease,

autoimmune)

Diabetic (symptoms worse in type 1)

Post-surgical

Others (*inpatients, often reversible):

Hyperglycemia (>12mM/L)

Post-viral (*CMV, EBV, VZV)

Medications

Medications

TCAs

Alpha-2-agonists (clonidine), CCBs

Dopamine agonists, muscarinic cholinergic

receptor antagonists

Octreotide

Phenothiazines

Cyclosporine

GLP1 Analogs (Liraglutide)

Opioids!

Medications: Opioids

Curr Treat Options Gastro (2016) 14:478–494

Medications: Opioids

Stomach & colon have highest numbers of mu

receptors1

Constipation most common GI adverse event, but

nausea, vomiting, bloating, GERD also common

Occurs with mixed agonists/antagonists as well

(ex. buprenorphine used in opiate detox)2

1. Curr Treat Options Gastro (2016) 14:478–494 2. Addiction. 2007 Mar;102(3):490-1

60-year-old on long-term morphine for chronic back pain, presenting with acute

abdominal painThe American Journal of the Medical Sciences Volume 350, Number 3, September 2015

Diagnosis

To establish a diagnosis patient must have

1. Symptoms

2. Gastric outlet obstruction ruled out

3. Documented delayed gastric emptying

Clinical guideline: management of gastroparesis.

Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.

Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.

Diagnosis: Key Tests

Gastric emptying study

4 hr solid phase gastric emptying

UGI series/Gastroscopy

Exclude mechanical obstruction (e.g. small bowel

mass, SMA syndrome)

Retained food after overnight fast suggestive

Other diagnostic tests

Capsule

Gastric motility study

Breath test

Gastric emptying study

Scintigraphic gastric emptying of solids

ie Tc sulfur colloid labeled egg salad sandwich

Most reliable parameter is gastric retention of

solids at 4 hours

Completed off medications that affect gastric

emptying > 48 hrs before testing

Gastric images obtained during simultaneous assessment of gastric emptying and accommodation. Hrair

P. Simonian et al. J Nucl Med 2004;45:1155-1160

(c) Copyright 2014 SNMMI; all rights reserved

Lab tests

CBC

Fasting glucose; A1c

Albumin

TSH

Consider AI workup+/- viral or paraneoplastic

workup

Management Principles

Modify what you can:

Tight glycemic control

Remove potential meds

Diet

Prokinetics

Symptom control: Anti-emetics

Tubes: Nutrition +/- Venting

Compassionate: Electrical stimulation

Management: Diet/lifestyle

Avoid:

fat (slows gastric emptying)

nondigestible (insoluble) fibre – requires effective

interdigestive antral motility

carbonated beverages (increase distension)

EtOH & smoking (decrease antral contractility)

Small, frequent meals (4-5/day)

Liquid meals if intolerant of solids

emptying of liquids is often normal

Management: Prokinetics

Metoclopramide

dopamine-2 receptor antag, 5-HT4 ag, weak 5-

HT3 receptor antag

↑ gastric antral contractions, ↓ postprandial fundus

relaxation

SEs: anxiety, restlessness, depression, ↑PRL, ↑QT

interval, dystonia (0.2%), tardive dyskinesia (1%)

Domperidone

dopamine 2 antagonist

SEs: ↑PRL, check QT interval

Management: Prokinetics

Erythromycin: 3rd line

Motilin agonist; causes high amplitude propulsive

gastric contractions

Can be used 3rd line after domperidone or

metoclopramide

Liquid TID 40 – 250 mg ac meals

Works best IV

≤4 weeks at a time: tachyphylaxis

SEs: ↑QT, abdo pain, ototoxicity, sudden death

No trials for azithromycin but might be as good

Management: Prokinetics

Cisapride

5HT4 Agonist

10-20 mg QID ac meals

Stimulates antral and duodenal motility which is

maintained long term

Major drug interactions: macrolides, antifungals,

phenothiazine

Resulted in cardiac arrhythmia and death: QT

interval

Special access Health Canada only; need to

monitor QT; ensure <450 msec

Management: Prokinetics

Prucalopride

5HT4 agonist

dose of 1 to 4 mg OD

safe and well tolerated

Management: Prucalopride

RCT: 34 pts with gastroparesis, 6 with DM

prucalopride 2 mg OD vs. placebo

4 weeks of therapy; 2-week washout, then

crossover

Gastric half-emptying time:

Signficant decrease in prucalopride group: 87.9

minutes vs. 118, P < .05

Also reduced scores for nausea/vomiting,

fullness/satiety, bloating/distension, and QOL

1 episode of intestinal volvulus, 1 diarrhea

resulting in discontinuationhttp://www.firstwordpharma.com/node/1327032#axzz4thfvA4RM

Management: Antiemetics

Antihistamines: e.g. Diphenhydramine

12.5 mg orally / IV q6-8h

5HT3 antagonists

ondansetron 4 - 8 mg TID

Management: refractory

symptoms

percutaneous endoscopic gastrostomy tube

decompress upper GI tract

Reduces need for hospitalization for acute

exacerbations of dysmotility

percutaneous endoscopic jejunostomy tube

enteral nutrition

unintentional weight loss 10% of more / 3-6 mos,

or repeated hospitalizations

Tube Selection

Tube Use Limitations

NG Gastric decompression

in acute mgmnt

Not long term;

uncomfortable; gastric

feeding

NE Trial feeding to see if

small bowel feeding

tolerable

Not long term; Migration

of tube particularly with

vomiting

PEG Venting, decompression,

drainage

Gastric feeding

PEG-J Venting and small bowel

feeding

Migration of tube; pyloric

obstruction

J Small bowel feeding No G venting

PEG and J Two sites – one for

venting and nutrition

Increased risk leaking,

infection

Clinical guideline: management of gastroparesis.

Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.

Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.

Management: Gastric electrical

stimulation

high-frequency gastric electrical stimulation

(12/minute)

compassionate treatment for refractory nausea &

vomiting

Systematic review: improves symptom severity &

gastric emptying a subset of pts (diabetic)

Gastric pacing: regular slow-wave rhythm

Impractical - external current source too large

Lal et al. Gastric electrical stimulation with the Enterra system: a systematic review. Gastroenterology research and practice 2015;1.

Take Home Points

1. Gastroparesis can cause severe

symptoms; suspect in diabetics, post op and

with opioids

2. Diagnostic work up includes gastroscopy,

UGI series, gastric emptying study

3. Modify what you can – glycemic control,

meds, diet

4. Prokinetics, diet and time are mainstays of

therapy

Questions