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Gastroparesis: A ContinuedChallenge
Management of the Complex Hospitalized PatientAugust 14, 2013
Randy P. Wright, MDAssistant Professor
Division of Gastroenterology & Nutrition
Camilleri M, Parkman HP, Shafi MA, Abell TL,Gerson L; American College of Gastroenterology.Clinical guideline: management of gastroparesis.Am J Gastroenterology. 2013 Jan;108(1):18-37
Objectives
Definition Epidemiology & Impact Diagnosis & Differential Management
Pharmacologic Surgical Gastric Electrical Stimulation
Definition
Objective delay in gastric emptying Absence of gastric outlet obstruction or
ulceration Symptoms
Postprandial fullness (early satiety) Nausea Vomiting Bloating MEG abdominal pain
Epidemiology
Prevalence: 24.2/100,000 9.6/100,000 male 37.8/100,000 female
Incidence 1996-2006 2.4/100,000 male 9.8/100,000 female
Epidemiology
Incidence in Olmsted County, MN DM1 4.8% DM2 1% Idiopathic 0.1%
DM gastroparesis Typically develops after DM 10 years Tends to persist despite improved glycemic control More likely to have cardiovascular disease, HTN,
retinopathy
Figure 1 Age-specific incidence of gastroparesis in Olmsted County, Minnesota, 19962006. ( A ) Definite gastroparesis. ( B )Definite plus probable gastroparesis. ( C ) Definite plus probable plus possible gastroparesis. *Comparison of incidence according...HyeKyung Jung , Rok Seon Choung , G. Richard Locke III , Cathy D. Schleck , Alan R. Zinsmeister , Lawrence A. Sza...
The Incidence, Prevalence, and Outcomes of Patients With Gastroparesis in Olmsted County, Minnesota, From 1996 to 2006
Gastroenterology Volume 136, Issue 4 2009 1225 - 1233
http://dx.doi.org/10.1053/j.gastro.2008.12.047
Epidemiology
QOL Hospitalizations have increased since 2000
Poor glycemic control Infection Noncompliance or intolerance of medications
Delayed gastric emptying study predicts: Morbidity Hospitalizations ED and doctor visits
Figure 3 Survival of gastroparesis inception cohort in Olmsted County, 19962006, and expected survival of the sex- and age-matched Minnesota white population in 2000 ( P = .0001). ( A ) Definite gastroparesis. ( B ) Definite plus probable gastroparesis. ...
HyeKyung Jung , Rok Seon Choung , G. Richard Locke III , Cathy D. Schleck , Alan R. Zinsmeister , Lawrence A. Sza...
The Incidence, Prevalence, and Outcomes of Patients With Gastroparesis in Olmsted County, Minnesota, From 1996 to 2006
Gastroenterology Volume 136, Issue 4 2009 1225 - 1233
http://dx.doi.org/10.1053/j.gastro.2008.12.047
Etiology
Idiopathic (IG) 36% DM (DG) 29% Postsurgical (PSG) 13% Parkinsonism Amyloidosis Paraneoplastic syndrome (SCLC, ovarian, etc.) Scleroderma Mesenteric ischemia
Etiology
Extrinsic: Post surgical vagal nerve injury
Fundoplication Peptic ulcer surgery Roux-en-Y bariatric surgery
Roux-en-Y stasis syndrome: Vagotomy predisposes to slowemptying from gastric remnant delayed transit of Rouxalimentary limb
www.hopkinsmedicine.com
Etiology
Extrinsic: Pharmacological blockade
GLP-1 analogs Exenatide (nausea 43% vomiting 12.8%), liraglutide NOT dipeptidyl peptidase IV inhibitors: sitagliptin, saxagliptin,
linagliptin, alogliptin Amylin analogs
pramlintide Narcotics - -opioid agonist
Less so with tramadol Cyclosporine
NOT tacrolimus (prokinetic properties)
Etiology
Enteric & Intrinsic mechanisms Loss of interstitial cells of Cajal (ICC)
pacemaker of the stomach - generate slow waves Loss of neuronal nitric oxide (nNOS)
DM neuropathy oxidative stress loss of ICC and nNOS
Etiology
Post Viral Sudden onset after prodrome illness Usually improves by about a year Autonomic neuropathy (CMV, EBV, VZV)
Slower resolution several years Worse prognosis
Etiology
Delayed gastric emptying longstanding DM1 Rapid gastric emptying early DM2
Vagal dysfunction due to DM or post surgical fundic accommodation gastric pressure rapid emptying of liquids
Figure 1 Pathophysiology of diabetic gastroparesis (Adapted from Gut , Kashyap P, Farrugia G, 2010;59:17161726,with permission from BMJ Publishing Group Ltd).Michael Camilleri , Adil E. Bharucha , Gianrico FarrugiaEpidemiology, Mechanisms, and Management of Diabetic GastroparesisClinical Gastroenterology and Hepatology Volume 9, Issue 1 2011 5 - 12http://dx.doi.org/10.1016/j.cgh.2010.09.022
Diagnosis
Symptomatic Exclusion of other etiologies and obstruction
with endoscopy or radiological imaging Biochemical screen for hypothyroid & DM EGD Enterography or barium UGI
Delayed gastric empting rather thangastroparesis if asymptomatic
Functional Dyspepsia vs.Gastroparesis
Symptom Functional dyspepsia Gastroparesis
Epigastric pain/discomfort 8990 8990
Epigastric fullness 7590
Early satiety 5082 6086Symptoms worsened byeating 79 72
Postprandial fullness 7588
Bloating 6896 5175
Belching 4585
Nausea 6790 9296
Vomiting 2033 6884
Weight loss 58
Lacy BE. Functional dyspepsia and gastroparesis: one disease or two? Am J Gastroenterology. 2012 Nov