9/14/2020 Critical illness induced gastroparesis - EMCrit Project

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Critical illness induced gastroparesis

September 14, 2020 by Josh Farkas

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CONTENTS

Basics (#basics)

Clinical presentation (#clinical_presentation)

Causes (#causes)

Differential diagnosis (#differential_diagnosis)

Evaluation (#evaluation)

Treatment (#treatment)

Podcast (#podcast)

Questions & discussion (#questions_&_discussion)

Pitfalls (#pitfalls)

PDF of this chapter (https://emcrit.org/wp-content/uploads/2017/01/hyperthermia.pdf)  (or create customized PDF (https://emcrit.org/ibcc/about-guide/#pdf) )

basics

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This chapter explores acute gastroparesis in the context of critical illness.  This often occurs due to a variety of physiological stressors, withsubsequent resolution over time.  Gastroparesis in the ICU is related to, but not identical to, gastroparesis encountered in an outpatient context.

clinical presentation

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Nausea, vomitingEarly satietyAbdominal painInability to tolerate tube feeding (e.g., vomiting with high residual volumes)

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causes

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infection

medications

Anticholinergic agents (including numerous medications such as diphenhydramine and tricyclic antidepressants)Beta-adrenergic agonistsCalcium channel blockersLevodopaNarcoticsOctreotideHyperosmolar feeding tube formulations

metabolic abnormalities

Adrenal insu�ciencyHyperglycemia (often due to diabetes)Hypoparathyroidism or hyperparathyroidismHypothyroidism or hyperthyroidismElectrolyte abnormalities

neurological disorders

Multiple sclerosisParkinson's diseaseStrokeElevated intracranial pressureDiabetic neuropathy

surgical / anatomic

Esophagectomy or gastric surgeryMesenteric ischemiaChest or abdominal surgery with injury of the vagus nerve

di�erential diagnosis

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Gastric outlet obstructionIleusSmall bowel obstruction

evaluation

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gastric residual volumes

Gastric residual volumes measured during tube feeding may be used to quantify the residual �uid in the stomach.Routine measurement of residual volumes in all patients does not appear to be bene�cial (in terms of a reduction in ventilator-associatedpneumonia).(23321763 (https://pubmed.ncbi.nlm.nih.gov/23321763/) )

Isolated elevation of gastric residual volumes without clinical signs of feeding intolerance (e.g., distension, nausea, or vomiting) doesn'trequire intervention. (28828195 (https://pubmed.ncbi.nlm.nih.gov/28828195/) )

If there is a clinical suspicion for gastroparesis (e.g., due to distension or vomiting), then gastric residual volume may be useful.Gastric residual volumes <250 ml argue strongly against gastroparesis.

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Gastric residual volume in the 250-500 ml range is nonspeci�c.  Different studies vary in what the upper limit of a “normal” gastricresidual volume is (with values ranging from 150 ml to 500 ml!).(28828195 (https://pubmed.ncbi.nlm.nih.gov/28828195/) )Gastric residual volumes >500 ml may raise more concern for impaired gastric motility.  However, this isn't speci�c to gastroparesis, butmay also occur with small intestinal ileus or mechanical obstruction.

abdominal X-ray

May reveal gastric distension.Its primary role is to exclude alternative diagnoses (e.g., illeus or mechanical small bowel obstruction).

further evaluation

There are other tests considered in the outpatient approach to this problem, including further imaging (CT or MRI) to rule out obstruction,upper endoscopy, and scintigraphic gastric emptying studies.  These are generally not used in the ICU setting.

treatment

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post-pyloric feeding tube

A post-pyloric small-bore feeding tube may provide a de�nitive solution for weeks.This might be an optimal bridge until gastric function resolves (as it often does with resolution of the underlying illness).If feasible, this has the advantage that it avoids medication side-effects.Careful maintenance is essential to avoid clogging these small-bore tubes.

removal of inciting causes

Avoid problematic medications (listed above (#causes) ).Achieve reasonable glucose control.

tube feeding formulation

Intuitively it might seem that concentrated, smaller-volume tube feeding would be helpful.  However, this may not be the case.  Concentratedtube feeds tend to be hyperosmolar and high in fat – both of which slow gastric emptying.

The TARGET trial found that patients receiving more energy-dense feeds (1.5 kCal/ml) experienced greater gastric residuals and morevomiting.  However, patients receiving denser feeds also received more calories, which could factor into this as well.(30346225(https://pubmed.ncbi.nlm.nih.gov/30346225/) )

erythromycin

Erythromycin stimulates motilin receptors in the gut, promoting gastric emptying.  ESPEN guidelines recommend erythromycin as the front-line promotility agent in the ICU. (30348463 (https://pubmed.ncbi.nlm.nih.gov/30348463/) )  The main drawback of erythromycin is that, over time,its use leads to tachyphylaxis (diminishing e�cacy) due to down-regulation of motilin receptors.  Thus, erythromycin often becomesineffective over roughly three days.The dose is 100-250 mg IV three times daily.   Gradual infusion over ~20 minutes may reduce adverse outcomes. (30294835(https://pubmed.ncbi.nlm.nih.gov/30294835/) )Contraindications include QT prolongation, acute hepatic injury, or myasthenia gravis.Side-effects may include hypotension, abdominal pain, nausea, vomiting, and diarrhea.(30855322 (https://pubmed.ncbi.nlm.nih.gov/30855322/) )More information:  Medscape monograph here (http://reference.medscape.com/drug/erythromycin-lactobionate-999597#0) .

metoclopramide

Metoclopramide affects a variety of receptorsIt is a central and peripheral dopamine (D2) antagonist.It has mixed serotonergic effects (partial antagonism of 5-HT3 receptors, with partial agonism of 5-HT4 receptors).It is a weak cholinesterase inhibitor.

Metoclopramide has a combination of useful effects:

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Anti-emeticPro-kinetic, affecting the stomach and duodenum (caused by D2-antagonism and 5HT4-agonism)

The dose is 10 mg IV three times daily, with a 50% dose reduction if the GFR is <50 ml/min.  Gradual infusion may reduce the incidence ofextrapyramidal side-effects.Metoclopramide may be used in combination with erythromycin to increase e�cacy (potentially the most effective strategy).(29720852(https://pubmed.ncbi.nlm.nih.gov/29720852/) )Contraindications include Parkinson's disease, seizure disorder, or prior adverse reaction to antipsychotics (e.g., dystonia or neurolepticmalignant syndrome).Side effects:

Antipyramidal side-effects (e.g., tardive dyskinesia, akathisia, dyskinesia, dystonia).  These are rare and associated mostly with chronicuse or higher dosages than are required when using metoclopramide as a pro-kinetic.Sedation and depression.

More information:  Medscape monograph here (http://reference.medscape.com/drug/reglan-metozolv-odt-metoclopramide-342051) .

gastrojejunostomy tube

This is essentially a durable, percutaneous post-pyloric feeding tube.  It may provide more durable, long-term nutrition.  In the uncommonevent that total parenteral nutrition (below) might be considered, use of a gastrojejunostomy tube is often preferable.Interventional radiology may place a venting gastrojejunostomy tube combination:  

One tube enters the stomach and transverses into the duodenum – this is used for feeding.Another lumen remains in the stomach and may be used to “vent” the stomach.

total parenteral nutrition (TPN)

This is the modality of last resort, which should be used only if all of the above treatments are impossible.Total parenteral nutrition is a highly undesirable treatment for isolated gastroparesis.  If the remainder of the bowel is functional (i.e., smallintestine and colon), then it is often preferable to obtain percutaneous or surgical access to the small bowel and provide enteral feeds (e.g.,gastrojejunostomy tube above).

podcast

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questions & discussion

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To keep this page small and fast, questions & discussion about this post can be found on another page here (https://emcrit.org/pulmcrit/hypomotility/) .

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Routine measurement of the gastric residual volume should be avoided.  This may lead to over-diagnosis and over-treatment of clinicallyasymptomatic gastric dysfunction.Over-utilization of total parenteral nutrition in patients with challenging gastric motility should be avoided.

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References

23321763  Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associatedpneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249-256.doi:10.1001/jama.2012.196377  [PubMed (https://pubmed.ncbi.nlm.nih.gov/23321763/) ]28818187  Vilz TO, Stoffels B, Strassburg C, Schild HH, Kalff JC. Ileus in Adults. Dtsch Arztebl Int. 2017;114(29-30):508-518.doi:10.3238/arztebl.2017.0508  [PubMed (https://pubmed.ncbi.nlm.nih.gov/28818187/) ]28828195  Vazquez-Sandoval A, Ghamande S, Surani S. Critically ill patients and gut motility: Are we addressing it?. World J GastrointestPharmacol Ther. 2017;8(3):174-179. doi:10.4292/wjgpt.v8.i3.174  [PubMed (https://pubmed.ncbi.nlm.nih.gov/28828195/) ]29720852  Ladopoulos T, Giannaki M, Alexopoulou C, Proklou A, Pediaditis E, Kondili E. Gastrointestinal dysmotility in critically illpatients. Ann Gastroenterol. 2018;31(3):273-281. doi:10.20524/aog.2018.0250  [PubMed (https://pubmed.ncbi.nlm.nih.gov/29720852/) ]30294835  Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of GastrointestinalMotility Disorders in the Acutely Ill. Nutr Clin Pract. 2019;34(1):23-36. doi:10.1002/ncp.10199  [PubMed (https://pubmed.ncbi.nlm.nih.gov/30294835/)

]30346225  TARGET Investigators, for the ANZICS Clinical Trials Group, Chapman M, Peake SL, et al. Energy-Dense versus Routine EnteralNutrition in the Critically Ill. N Engl J Med. 2018;379(19):1823-1834. doi:10.1056/NEJMoa1811687  [PubMed(https://pubmed.ncbi.nlm.nih.gov/30346225/) ]30855322  Plummer MP, Reintam Blaser A, Deane AM. Gut dysmotility in the ICU: diagnosis and therapeutic options. Curr Opin Crit Care.2019;25(2):138-144. doi:10.1097/MCC.0000000000000581  [PubMed (https://pubmed.ncbi.nlm.nih.gov/30855322/) ]

The Internet Book of Critical Care is an online textbook written by Josh Farkas (@PulmCrit), an associate professor ofPulmonary and Critical Care Medicine at the University of Vermont.

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