Download - Gastroparesis
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Abeezar I. SarelaConsultant in Upper GI & Bariatric Surgery
Hinduja Hospital, MumbaiSt James’s University Hospital, Leeds, UK
Gastric Motility Disorders
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Case Study
• 52 year old woman
• Fullness after a small meal
• Continuous nausea
• 6-8 episodes of vomiting daily
• Upper abdominal bloating
• Diabetes– Insulin, Metformin, Exenatide
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Endoscopy
Barium Meal and Follow-Through
CT scan
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Functional Dyspepsia?
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Gastroparesis
Delayed gastric emptying in
the absence of mechanical
obstruction of the stomach
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True Prevalence?
25-40%
of “dyspeptic” patients
American Gastroenterological Association Technical Review on the Diagnosis and Treatment of Gastroparesis. Gastroenterology 2004;127:1592-1622
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Aetiology of Gastroparesis• Idiopathic
• Diabetes mellitus
• Post-surgical– Partial gastric resection/vagotomy– Bariatric surgery– Anti-reflux surgery
• Associated with other GI disorders
• Associated with Non-GI disordersAmerican Gastroenterological Association Technical Review on the Diagnosis and
Treatment of Gastroparesis. Gastroenterology 2004;127:1592-1622
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Diabetic Gastroparesis
5-12% of diabetics
Long duration of disease ~ 10 years
Neuropathy, nephropathy, retinopathy
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Diabetic Gastroparesis
• Destabilisation of blood glucose control
– Alteration in drug absorption
– Unpredictable delivery of food into intestine
• Hyperglycemia affects gastric motility
• Problems with blood glucose control may
be first indication of gastroparesis
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Diagnosis
Nuclear Medicine
Gastric Scintigraphy
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Normal Liquid Emptying from Stomach
ExponentialCurve ~Measure
T½
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Normal Emptying of Solid Food from Stomach
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Normal Emptying of Solid Food from Stomach
Linear Pattern ~ Measure ProportionRetained in Stomach
At 1 hours and 4 hours
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Measuring Gastric Emptying
Dual Phase Scintigraphy
Scintigraphy uses different radionuclides for labeling the liquid
and solid elements of the meal so that emptying curves for both phases are
obtained simultaneously
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Normal Gastric Emptying
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Normal Pattern
• Liquid phase
– T½ less < 30 minutes
• Solid phase
– at least 25% of the meal leaves the stomach
by 60 minutes
– <15% is retained in the stomach at 4 hours
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Gastroparesis
solid
liquid
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liquid
solid
Gastroparesis
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Gastric Emptying
N Eng J Med 2007;356:820-829
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Other Tests
• 13C Labelled Octanoate Breath Test
• Antroduodenal Manometry
• Electrogastrography
• Ultrasound
• Magnetic Resonance Imaging
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Why is Scintigraphy the Investigation of Choice?
• Simple
• Non-invasive
• Very small radio-active dose
• Physiological
• Prolonged observation
• Quantifiable
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Severity of GastroparesisMild Moderate Severe
Retention at
4 hours
10-15% 16-35% >35%
Homogenised food Rare Sometime Routine
Nutritional supplements
Rare By mouth Jejunal tube
Non-pharmacologic
treatment
No No Yes
N Eng J Med 2007;356:820-829
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Treatment of Gastroparesis
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1. Correction of Exacerbating Factors
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2. Nutrition
Homogenised Diet
Jejunal Tube Feeding
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3. Symptomatic Treatment
• Macrolides– Erythromycin
• Dopamine Receptor Antagonists– Metoclorpromide
– Erythromycin
• Anti-emetics
• Analgesia
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3. Symptomatic Treatment
• Botox injection at pylorus
• Surgery
• Gastric Electrical Stimulation
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Gastric Smooth Muscle Function
• Gastric slow waves (Phasic): 3/min
– Bradygastria, Tachygastria, Gastric Dysrhythmia
• Tonic spikes superimposed on slow waves result in smooth muscle contraction
Soffer et al. Aliment Pharmacol Ther 2009;30:681-694
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Gastric Electrical Stimulation (GES)
Gastric Pacing:• Entrain slow waves• Low-frequency + Long duration• Implantable Pulse Generator
(IPG) not available
Implantable GES• High frequency + Short duration• Slow waves not altered• Neural stimulation
Clinically Used GES is NOT pacing
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Enterra™ Therapy (Medtronics) for Gastroparesis
• Humanitarian Device Exemption approval from the US FDA in 2000
• Handheld, external programmer to adjust the neurostimulator and customize therapy
• Therapy can be turned off at any time
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Electrophysiology of Enterra™ Therapy
High-Frequency stimulation with
trains of
Short-Duration pulses
Soffer et al. Aliment Pharmacol Ther 2009;30:681-694
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Enterra™: Position of Electrodes
9 cm
10 cm
1 cm
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Implantation of Enterra™ Electrodes
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Enterra™ Therapy
• ~ 1000 devices used world-wide
• Largest experience:
– University of Mississippi Medical Centre, Jackson, USA
– ~ 600 cases
• UK
– 8 regional centres
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• Improvement in one of three parameters: 90%– Health Related Quality of Life Score
• Improved to 16.3 from 10.6
– Vomiting Frequency Score • Decreased to 1.9 [0.1] from 2.9 [0.1]
– Total GI Symptom Score • Decreased to 10.9 [0.2] from 15.6 [0.3]
• Gastric Emptying– Two-hour retention fell from 55% to 42%– Four-hour retention fell from 26% to 17%
Results of Enterra™ Therapy
214 patients. 1992-2005. Univ. of Miss Med Ctr. Anand et al. Digestion 2007;75:83-89
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Predictors of Poor Outcome
• Predominant symptoms: pain and bloating
• Idiopathic gastroparesis
• Loss of interstitial cells of Cahal on full thickness gastric biopsy
• Electrogastrogram: tachygastric rhythm
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Endoscopy-Placed, Trans-Nasal Electrodes:
Evaluation of Response to Temporary Therapy
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Gastroparesis
• Commoner than we think
• Radio-labelled scintigraphy
• Optimise diabetes treatment
• Nutrition
• Symptom-control
• Enterra™
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Controversies
• Quality of evidence: Weak– Only one RCT – poor– Variable scoring systems– Attrition bias
• Confounded by concurrent pharmacotherapy
• Relationship between delayed emptying and symptoms is unclear
• Mechanism of action is unclear