Presentation Gastroparesis

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Treatment of RefractoryGastroparesisSunjay Barton MS3

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Case

• 49-year-old man with history of poorly controlleddiabetes and multiple hospitalizations for acute

exacerbations of gastroparesis

• Diagnosed with gastric scintigraphy, wireless

motility capsule

• Recurrent nausea, vomiting, severe crampy

abdominal pain

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Failed medical treatments: diet modification

•  Avoid fat (slows gastric emptying) and insolublefiber

• Small, frequent meals

• Blend food (liquid = rapid transit)

•  Avoid alcohol/smoking (decreases motility)

• Optimize glycemic control

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Failed medical treatments: metoclopramide

• Patient developed legtwitching concerning

for extrapyramidal

symptoms vs tardive

dyskinesia

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Failed medical treatments: erythromycin

• Patient developed side effects of muscleweakness and blurred vision

• Patient discontinued medication after one week

• Interaction with statins (rhabdomyolysis, AKI)

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 Additional medical treatment options

• Domperidone (D2 antagonist; difficult to obtain inUS)

•  Azithromycin

• Cisapride (5HT4 agonist; difficult to obtain in US)

•  Anti-emetics: diphenhydramine, ondansetron,

prochlorperazine, TCAs

• Scopolamine, aprepitant, dronabinol have beenused, but no evidence for effectiveness

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Previous surgical treatment: Botox pyloroplasty

• Temporarily relieved patient’s symptoms • No benefit in RCTs

• Not recommended in American College of

Gastroenterology guidelines for management ofgastroparesis [1]

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 Additional treatments: G tube / J tube

• Gastrostomy tube placement for decompression• Jejunostomy tube placement for feeding in patients

with significant weight loss

• G tube +/- J tube reduced number ofhospitalizations 5-fold in prospective trial of 22

patients [3]

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Gastric electrical stimulation: hardware

• Battery pack implantedin abdominal wall

• Electrodes deliver low

energy electrical

stimulation to stomach

at 12 cycles per

minute

• Physiologicoscillations are 3 cpm

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Gastric electrical stimulation: evidence

• Humanitarian device exemption for refractorydiabetic or idiopathic gastroparesis

• Double-blind, randomized crossover study of 33

patients in 2003 demonstrated reduction of weekly

vomiting frequency and improvement in quality of

life [4]

• Significant improvement seen in diabetic subgroup

as well as whole cohort

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Gastric electrical stimulation: mechanism

• Unclear• No effect on gastric emptying

• Increases maximal tolerated gastric distention

• Research continues on devices that deliver

physiologic low frequency gastric pacing, currently

too large for implantation

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Summary

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Sources

1. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical

guideline: management of gastroparesis. The American journal ofgastroenterology. 2013;108:18-37.

2. Hibbard ML, Dunst CM, Swanstrom LL. Laparoscopic and

endoscopic pyloroplasty for gastroparesis results in sustained symptom

improvement. Journal of gastrointestinal surgery: official journal of the

Society for Surgery of the Alimentary Tract. 2011;15:1513-9.

3. Borrazzo EC. Surgical management of gastroparesis:

gastrostomy/jejunostomy tubes, gastrectomy, pyloroplasty, gastric electrical

stimulation. Journal of gastrointestinal surgery: official journal of the Society

for Surgery of the Alimentary Tract. 2013;17:1559-61.4. Abell T, McCallum R, Hocking M, et al. Gastric electrical stimulation

for medically refractory gastroparesis. Gastroenterology. 2003;125:421-8.