diagnosis and management of gastroparesis...2018/11/21 · • medications that affect gastric...
TRANSCRIPT
![Page 1: Diagnosis and Management of Gastroparesis...2018/11/21 · • Medications that affect gastric emptying should be stopped at least 48 h. • Hyperglycemia should be corrected before](https://reader034.vdocument.in/reader034/viewer/2022042217/5ec08692e5d959619f19351c/html5/thumbnails/1.jpg)
Diagnosis and Management of
Gastroparesis
Bible Class 21.11.2018 / I. Linas
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Bible Clas 21.11.18/ I.Linas 2
Universitätsklinik für Viszerale Chirurgie und Medizin
Case 1: 20 year old male
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Bible Clas 21.11.18/ I.Linas 3
Universitätsklinik für Viszerale Chirurgie und Medizin
Case 1: 20 year old male
• Presents as an outpatient after a hospital stay in the internal medicine ward for
unclear transient periumbilical pain
• Intermittent episodes of periumbilical pain (1x/2M) and
• Recurrent progressive postprandial fullness and vomiting for 8M with weight
loss (8-10 Kg).
• Fatigue, cannot play football any more like before
• Otherwise healthy
• Normal western diet, no alcohol, no smoking
• Family history: Parents emigrated from Kosovo, otherwise unremarkable
• Current medications: Paracetamol, Metamizol as needed
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Bible Clas 21.11.18/ I.Linas 4
Universitätsklinik für Viszerale Chirurgie und Medizin
Case 1: 20 year old male
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Bible Clas 21.11.18/ I.Linas 5
Universitätsklinik für Viszerale Chirurgie und Medizin
Case 1: 20 year old male
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Bible Clas 21.11.18/ I.Linas 6
Universitätsklinik für Viszerale Chirurgie und Medizin
- 21.08.2017 Sonografie Abdomen: keine akute Appendizitis, keine anderen Pathologien
- 09.11.2017 Oesophago-Gastro-Duodenoskopie: Normalbefund im oberen Gastrointestinaltrakt.
- 13.11.2017 Histopathologie Duodenal- und Magenschleimhaut:
keine histopathologischen Veränderungen. Keine chronische oder aktive Entzündung.
- 09.11.2017 Helicobacter pylori negativ.
- 24.11.2017 Zöliakieabklärung: Gliadin(DP)-Antikörper IgG und IgA negativ,
Antikörper gegen Transglutaminase IgA negativ.
- 21. und 23.01.2018 Sonografie Abdomen: keine intraabdominellen Pathologien
- 24.01.2018 Laboruntersuchung und Urinstatus: bland
- 24.01.2018 CT Abdomen: keine relevanten Pathologien
- 25.01.2018 Serologie: Hepatitis B und C Virus HIV negativ
- 26.01.2018 Stuhlanalyse: Nukleinsäuresequenz für allgemeine Enteritis Erreger negativ,
Mikroskopie ohne mikroskopisch nachgewiesenen Darmparasiten
- 26.01.2018 Urinuntersuchung auf Porphyrie: keine Hinweise auf akute Porphyrie
- 26.01.2018 Sonografie Abdomen: Keine Rektusdiastase. Keine Umbilikalhernie.
- 29.01.2018 Koloskopie: kein Korrelat für die Beschwerden des Patienten. Biopsate, Ileum und
Kolonschleimhaut ohne histopathologische Veränderungen.
- 30.01.2018 Toxikologisches Screening Urin: unauffällig
Case 1: 20 year old male
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Bible Clas 21.11.18/ I.Linas 7
Universitätsklinik für Viszerale Chirurgie und Medizin
Does the patient have a gastroparesis? Why/Why not?
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Bible Clas 21.11.18/ I.Linas 8
Universitätsklinik für Viszerale Chirurgie und Medizin
Definition of Gastroparesis
The diagnosis of gastroparesis is based on the combination of
• symptoms of gastroparesis,
• absence of gastric outlet obstruction or ulceration, and
• delay in gastric emptying.
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Bible Clas 21.11.18/ I.Linas 9
Universitätsklinik für Viszerale Chirurgie und Medizin
Symptoms of gastroparesis?
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Bible Clas 21.11.18/ I.Linas 10
Universitätsklinik für Viszerale Chirurgie und Medizin
Symptoms of gastroparesis?
• early satiety,
• postprandial fullness,
• nausea,
• vomiting,
• bloating,
• upper abdominal pain
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Bible Clas 21.11.18/ I.Linas 11
Universitätsklinik für Viszerale Chirurgie und Medizin
Do symptoms correlate with gastric emptying?
• early satiety,
• postprandial fullness,
• nausea,
• vomiting,
• bloating,
• upper abdominal pain
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Bible Clas 21.11.18/ I.Linas 12
Universitätsklinik für Viszerale Chirurgie und Medizin
Case 1: 20 year old male
The diagnosis of gastroparesis is based on the combination of
• symptoms of gastroparesis
• absence of gastric outlet obstruction or ulceration
• delay in gastric emptying.
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Bible Clas 21.11.18/ I.Linas 13
Universitätsklinik für Viszerale Chirurgie und Medizin
Normal gastrointestinal motor function
- Modulated through vagal (parasympathetic) and sympathetic stimuli, locally
released transmitters and luminal input.
- Initiated by pacemaker cells (interstitial cells of Cajal)
- Spread to smooth muscle cells through the intrinsic (enteric) nervous system,
which also serves as a communication network
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Bible Clas 21.11.18/ I.Linas 14
Universitätsklinik für Viszerale Chirurgie und Medizin
Normal gastrointestinal motor function
• Proximal stomach: changes in tone in response to eating,
• Distal stomach: max 3cpm phasic contractions that propagate to the pylorus
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Bible Clas 21.11.18/ I.Linas 15
Universitätsklinik für Viszerale Chirurgie und Medizin
Do we need to measure gastric emptying?
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Bible Clas 21.11.18/ I.Linas 16
Universitätsklinik für Viszerale Chirurgie und Medizin
No! Not at this stage!Of course!
• accelerated gastric emptying and
functional dyspepsia can also
present similarly
• Documentation of delayed gastric
emptying is necessary before
selecting therapy with prokinetics
agents or GES.*Tack J , Bisschops R , Sarnelli G . Pathophysiology and treatment of
functional dyspepsia . Gastroenterology 2004 ; 127 : 1239 – 55 .
*Bredenoord AJ , Chial HJ , Camilleri M et al. Gastric accommodation
and emptying in evaluation of patients with upper gastrointestinal
symptoms . Clin Gastroenterol Hepatol 2003 ; 1 : 264 – 72 .
Janssen P, Tack J et al. Am J
Gastroenterol. 2013
Sep;108(9):1382-91
Do we need to measure gastric emptying?
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Bible Clas 21.11.18/ I.Linas 17
Universitätsklinik für Viszerale Chirurgie und Medizin
*Tack J , Bisschops R , Sarnelli G .
Pathophysiology and treatment of functional
dyspepsia . Gastroenterology 2004 ; 127 : 1239 –
55 .
Let’s take a closer look
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Bible Clas 21.11.18/ I.Linas 18
Universitätsklinik für Viszerale Chirurgie und Medizin
*Tack J , Bisschops R , Sarnelli G .
Pathophysiology and treatment of functional
dyspepsia . Gastroenterology 2004 ; 127 : 1239 –
55 .
Let’s take a closer look
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Bible Clas 21.11.18/ I.Linas 19
Universitätsklinik für Viszerale Chirurgie und Medizin
*Tack J , Bisschops R , Sarnelli G .
Pathophysiology and treatment of functional
dyspepsia . Gastroenterology 2004 ; 127 : 1239 –
55 .
Let’s take a closer look
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Bible Clas 21.11.18/ I.Linas 20
Universitätsklinik für Viszerale Chirurgie und Medizin
*Bredenoord AJ , Chial HJ , Camilleri M et al.
Gastric accommodation and emptying in
evaluation of patients with upper gastrointestinal
symptoms . Clin Gastroenterol Hepatol 2003 ; 1 :
264 – 72
• Retrospective study on 214 patients that underwent
SPECT to assess gastric accommodation and 4h
scintigraphy
Let’s take a closer look
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Bible Clas 21.11.18/ I.Linas 21
Universitätsklinik für Viszerale Chirurgie und Medizin
Methods of measuring gastric emptying?
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Bible Clas 21.11.18/ I.Linas 22
Universitätsklinik für Viszerale Chirurgie und Medizin
Methods of measuring gastric emptying?
• Solid meal 4-hour gastric emptying scintigraphy
• Wireless motility capsule
• C-13 breath testing
• Medications that affect gastric emptying should be stopped at least 48 h.
• Hyperglycemia should be corrected before the test.
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Bible Clas 21.11.18/ I.Linas 23
Universitätsklinik für Viszerale Chirurgie und Medizin
What about our method?
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Bible Clas 21.11.18/ I.Linas 24
Universitätsklinik für Viszerale Chirurgie und Medizin
Gastric emptying T 1 / 2
Siegel JA et al. Biphasic nature of gastric
emptying . Gut 1988 ; 29 : 85 – 9
Acceptable if
• imaging has been performed for 4 h or
• at least to 50 % emptying
*extrapolation to measure t 1 / 2 may be
erroneous
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Bible Clas 21.11.18/ I.Linas 25
Universitätsklinik für Viszerale Chirurgie und Medizin
Case 1: 20 year old male
• Gastric emptying study
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Bible Clas 21.11.18/ I.Linas 26
Universitätsklinik für Viszerale Chirurgie und Medizin
Causes of secondary gastroparesis?
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Bible Clas 21.11.18/ I.Linas 27
Universitätsklinik für Viszerale Chirurgie und Medizin
Causes of secondary gastroparesis
• Diabetes mellitus (30%)
• thyroid dysfunction
• neurological disease
• prior gastric or bariatric surgery (13%)
• autoimmune disorders
36% idiopathic
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Bible Clas 21.11.18/ I.Linas 28
Universitätsklinik für Viszerale Chirurgie und Medizin
How to diagnose autonomic dysfunction?
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Bible Clas 21.11.18/ I.Linas 29
Universitätsklinik für Viszerale Chirurgie und Medizin
Plasma pancreatic polypeptide response to sham feeding
• Controls and diabetic subjects
without AN: significant mean
60% increase
• AN: no significant hPP response
occurred
Buysschaert M, Donckier J, et al. Diabetes 1985; 34:1181-1185.
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Bible Clas 21.11.18/ I.Linas 30
Universitätsklinik für Viszerale Chirurgie und Medizin
Management of Gastroparesis, first steps?
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Bible Clas 21.11.18/ I.Linas 31
Universitätsklinik für Viszerale Chirurgie und Medizin
General measures
• restoration of fluids and electrolytes
• nutritional support
• (optimization of glycemic control)
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Bible Clas 21.11.18/ I.Linas 32
Universitätsklinik für Viszerale Chirurgie und Medizin
General measures
• restoration of fluids and electrolytes
• nutritional support?
• (optimization of glycemic control)
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Bible Clas 21.11.18/ I.Linas 33
Universitätsklinik für Viszerale Chirurgie und Medizin
Nutritional Support
• Counseling from a dietician
• Frequent small volume meals
• Low in fat and soluble fiber.
• If unable to tolerate solid food, then use of homogenized or liquid nutrient
meals is recommended.
• If no oral intake -> NJS trial -> jejunostomy
Loss > 10 % or more of the usual body weight during a period of 3 – 6
months
repeated hospitalizations for refractory symptoms.
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Bible Clas 21.11.18/ I.Linas 34
Universitätsklinik für Viszerale Chirurgie und Medizin
Nutritional Support
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Bible Clas 21.11.18/ I.Linas 35
Universitätsklinik für Viszerale Chirurgie und Medizin
Pharmacologic therapy?
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Bible Clas 21.11.18/ I.Linas 36
Universitätsklinik für Viszerale Chirurgie und Medizin
Pharmacologic therapy
• Metoclopramide = Domperidone
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Bible Clas 21.11.18/ I.Linas 37
Universitätsklinik für Viszerale Chirurgie und Medizin
Pharmacologic therapy
• Metoclopramide = Domperidone
• Erythromycin
• (Antiemetics)
• (TCAs)
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Bible Clas 21.11.18/ I.Linas 38
Universitätsklinik für Viszerale Chirurgie und Medizin
STW-5 (Iberogast)
• Relaxes Fundus and at the same time increases contractile waves in antrum
• Improves symptoms and motility
• 618 pat, UEGW 2018 (poster)
• Risks?
Hohenester B. et al. Neurgoastroenterol Motil 2004:16 765.73
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Bible Clas 21.11.18/ I.Linas 39
Universitätsklinik für Viszerale Chirurgie und Medizin
Prucalopride
Gastric emptying after 7 days on prucalopride
Prucalopride significantly accelerates gastric, small bowel and ascending colon
emptying in patients with FD or C-IBS.
Bouras EP, Camilleri M et al. Gastroenterology. 2001 Feb;120(2):354-60.
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Bible Clas 21.11.18/ I.Linas 40
Universitätsklinik für Viszerale Chirurgie und Medizin
No response to medical therapy
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Bible Clas 21.11.18/ I.Linas 41
Universitätsklinik für Viszerale Chirurgie und Medizin
Interventional therapies
• G-POEM
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Bible Clas 21.11.18/ I.Linas 42
Universitätsklinik für Viszerale Chirurgie und Medizin
G-POEM
Kahaleh M et al. Endoscopy. 2018 Nov;50(11):1053-1058
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Bible Clas 21.11.18/ I.Linas 43
Universitätsklinik für Viszerale Chirurgie und Medizin
Kahaleh M et al. Endoscopy. 2018 Nov;50(11):1053-1058
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Bible Clas 21.11.18/ I.Linas 44
Universitätsklinik für Viszerale Chirurgie und Medizin
Interventional therapies
• G-POEM
• Intrapyloric Botox-injection
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Bible Clas 21.11.18/ I.Linas 45
Universitätsklinik für Viszerale Chirurgie und Medizin
Intrapyloric Botox in patients with delayed gastric emptying
Arts J et al. Aliment Pharmacol Ther. 2007 Nov 1;26(9):1251-8.
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Bible Clas 21.11.18/ I.Linas 46
Universitätsklinik für Viszerale Chirurgie und Medizin
Interventional therapies
• G-POEM
• Intrapyloric Botox-injection
• Gastric electrical stimulation
![Page 47: Diagnosis and Management of Gastroparesis...2018/11/21 · • Medications that affect gastric emptying should be stopped at least 48 h. • Hyperglycemia should be corrected before](https://reader034.vdocument.in/reader034/viewer/2022042217/5ec08692e5d959619f19351c/html5/thumbnails/47.jpg)
Bible Clas 21.11.18/ I.Linas 47
Universitätsklinik für Viszerale Chirurgie und Medizin
Gastric electrical stimulation
• > 20 Trials, only 3 RCTs (4th coming?)
• 2 negative, 1 partly positive
• Diabetic > idiopathic
• No effect on gastric emptying
• Nonresponse, infection, electrode dislocation lead to explantation in up to 10%
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Bible Clas 21.11.18/ I.Linas 48
Universitätsklinik für Viszerale Chirurgie und Medizin
Interventional therapies
• G-POEM
• Intrapyloric Botox-injection
• Gastric electrical stimulation
• Surgery
Feeding jejunostomy + venting Gastrostopy
(Gastrojejunostomy)
(Gastrectomy)
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Bible Clas 21.11.18/ I.Linas 49
Universitätsklinik für Viszerale Chirurgie und Medizin
Thank you for your attention