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Diabetic Gastroparesis
Ali DjumhanaDiv. Gastroenterology dan Hepatologi
Bagian Ilmu Penyakit Dalam RS Hasan Sadikin – FK Unpad
Bandung
Gastroparesis
Gastroparesis is a form of gastric paralysis ;chronic symptoms may result from abnormal gastric motility associated with delayed gastric emptying in the absence of mechanical outlet obstruction.
The symptoms that suggest gastroparesis are variable include nausea, vomiting, abdominal bloating, early satiety , and abdominal pain or discomfort
The symptoms may mimic structural disorders (PUD,intestinalobstruction,pancreatobliary disorders) and there also overlap between symptoms of gastroparesis and FD
Relationship of symptoms to gastric motor function is poor Parkman HP ( 2004); Park MI(2006)
Etiology of Gastroparesis
28%
8%
29%
14%
10%
4%4% 3%
Idiopathic
Postviral
Diabetic
Postsurgical
Parkinsons
Pseudoobstruction
Scleroderma
Miscellaneous
Soykan I et al. (1998)
Epidemiology Female > Male (~ 4:1) Delayed gastric emptying were found
:– 20 - 40 % of pts with F D– 26 - 68% % of pts with Diabetes
Incidence of delayed gastric emptying:– 4.5% DM 1– 1% DM 2– 0.1%Non DM
Physiology of Gastric motility
=Parasympatetic ( N Vagus)=Sympatetic=Enteric neural system=Neurotransmitter (Acetylcholine,dopamin,serotonin)=Hormone ( glucose regulating
hormone)=Food composition (fat,CHO,solid,fluid)
Regulation of gastric motility
Physiology of gastric motilityMotor function of stomach is controlled at three main levels Autonomic nervous system Enteric neuronal system Interstitial Cell of Cajal Smooth muscle cell
Several subsystems are involved: afferent receptors neurohumoral substances circulating hormones
ICCsICCs
Motility of the gut
excitation
inhibition
Physiology of gastric emptying
Gastric emptying results of : Tonic contraction of the fundus, Phasic contraction of the antrum, Inhibitory forces of pyloric and
duodenal contraction
Pathophysiology Diabetic gastropsresis
Gut 2010;59:1716-1726
Pathophysiology Diabetic gastroparesis
Pathophysiology of Gastroparesis
Abnormal gastric motility Abnormal gastric accommodation Gastric dysrhythmias Antral hypomotility
Evaluation of patients suspected gastroparesis
Gastroparesis is diagnosed by demonstrating delayed gastric emptying in a symptomatic individual after exclusion of other etiologies of symptoms
Gastroparesis is often suspected in patient subgroup with specific profile DM After vagotomy FD GERD
Parkman HP ( 2004); Rayner CK (2005)Park MI(2006)
Evaluation of patients suspected gastroparesis
HT and PELaboratory testingEvaluation for organic disordersEvaluation for delayed gastric emptyingEvaluation of response to treatment trialFurther evaluation
History taking and Physical Examination
HT Differentiated of vomiting from regurgitation and ruminating Risk factors
Poor glycaemic controlled Female
History of medication (GLP-1 agonist/receptor analogue,etc) PE
Hydration status Nutrition status Succussion splash
Diagnosis
Gut 2010;59:1716-1726
Evaluation of patients Suspected Gastroparesis
Test to assess gastric motor and myoelectrical function
Assessing gastric emptying Upper Ba radiography study Scintigraphy USG MRI Breath test
Assessing gastric contractility Antroduodenal manometri Gastric barostat Satiety test
Assessing electrical activity EGG
Treatment of symptomatic gastroparesis
Nutrition teraphy– Hydration and corection of electrolite imbalance– Liquid or parenteral nutrition– Micronutrient– Vitamins ( Cobalamin,vitamin C, etc)
To tighten glicaemic control Prokinetic agents Anti emetic agents Others modality
– Botulinum injection– Gastric electrical stimulation– Gastrostomy and jejunostomy placement– Surgical treatment
Treatment of symptomatic gastroparesis
Dietary modification– Liquid diet is recommended to patient with
gastroparesis who have delayed solid emptying
– Frequent (4 – 5 x daily) and small size diet– Minimized fat and fiber intake– Avoid alcohol and carbonated beverages
To tighten glicaemic control.
Treatment of symptomatic gastroparesis
Medical treatment Prokinetic agent
– Dopaminergic agent Dopaminergic antagonist
– Metoclopramide– Domperidone– Mosapride
– Serotonergic agent 5HT4 agonist
– Pucalopride– Cisapride– Tegaserod
5HT3 antagonist– Ondansetron,granisetron
– Motilin agonist Eritromycin
Antiemetic agent– Phenotiazine
Psychotropic – Benzodiazepin– Antidepresant
New and other agents Motilides
– Mitemcinal– ABT 229
CCK antagonist– Loxiglumide
NO donors– Sidenafil ?
Ghrelin 5 HT1 agonist
– Sumatriptan– Buspiron
Treatment of symptomatic
gastroparesis
Commonly used prokinetic drugs
Rayner CK and Horowitz M (2005) New management approaches for gastroparesisNat Clin Pract Gastroenterol Hepatol 2: 454–462 doi:10.1038/ncpgasthep0283
Treatment of symptomatic gastroparesis
Others therapeutic modalities Endoscopic treatment
– Botulinum toxin injection Gastric electric stimulation Gastrostomy and jejunostomy placement Ginger, Acupuncture Surgical treatment
Improvement
Presumptive diagnosis of gastroparesis
Assessment of patients to rule out mechanical obstruction or another diseases
Nutrition;glycaemic controlEmpiric trial of prokinetic for 4-8 wks
History of symptoms gastroparesis
No improvement
Treatment continueAnd Pulse Tx
Perform UG-Endos/ Ba meal
Negative finding Structural lesion
Appropriate Tx High dose medical Tx
Test Gastric emptying
Improvement No ImprovementAbnormal Normal
High dose prokineticOr other modalities Re-evaluate the D/
Improvement
Conclusion (1)
Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction
Diabetic gastroparesis is the main cause of gastroparesis
Scintigraphy is a gold-standard for diagnosis
Conclusion (2)Patients with presumptive diagnosis
gastroparesis should be cared for empirical / trial treatment.
The treatment include ;Nutrition teraphy (Macro and micro nutrient,vitamins etc), metabolic control and prokinetic agent
Novel treatment including new prokinetics, botulinum toxin injection,gastric electrical stimulation have been tested in patients with gastroparesis