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Take home points: August 2015

Gastroparesis: Part 1

  • GP is a condition in which stomach contents do not move into the small intestine in an appropriate time frame without an obvious anatomical reason
  • GP patients can have severe symptoms, including nausea, vomiting, abdominal pain and bloating
  • GP can be episodic or chronic
  • The degree of gastric emptying delay does not impact symptom severity
  • GP may affect up to 2% of the population
  • GP is increasing over the last twenty years with no clear reason as to why
  • Cisapride is effective for treating GP but was removed from the market
  • GP symptoms are generic and make the cause hard to identify
  • Idiopathic GP has no clear cause and affects up to 1/3 of GP patients

Gastroparesis: Treatment (Part 2)

  • Treating dehydration and electrolyte and nutritional deficiencies are key to initial GP management
  • 64% of GP patients do not consume enough daily calories
  • Vitamins A, B6, C and K, iron, potassium and zinc are often deficient in GP patients
  • Small meals with low fat and fiber are recommended
  • Liquids or blended solids often empty normally from stomach
  • Feeding tubes may be placed if malnutrition is significant
  • Metoclopramide is approved for GP but use longer than twelve weeks carries risks like dystonia
  • Domperidone is not approved in US for GP but can be imported through a special FDA program for GP
  • Medications to increase gastric motility, like erythromycin, are often used
  • Medications for nausea and vomiting are common, such as ondansetron, scopolamine, draonabinol and tricyclic antidepressions
  • Nortriptyline and desipramine are tricyclics of choice as amitryptline can cause delayed gastric emptying
  • Opiates can induce GP so meds like gabapentin, tramadol, tapentadol, pregabalin and nortriptyline are preferred for abdominal pain
  • Botox injection into pyloric sphincter can increase gastric emptying but doesn’t always improve symptoms
  • Acupuncture and gastric pacemaker are also options

Gastroparesis: Diabetes and gastroparesis (Part 3)

  • 40% of patients with type I diabetes have delayed gastric emptying
  • 20% of patients with type II diabetes have delayed gastric emptying
  • In 2004, 26.7% of GP patients had diabetes
  • Diabetic patients with GP are more likely to have nausa and vomiting as predominant symptoms
  • GP can hinder effective blood sugar management
  • High blood sugar is associated with GP and vagus nerve damage
  • Gastric electric stimulation (gastric pacemaker) works better when GP is caused by diabetes than GP from other causes
  • Effective GP management improves blood sugar management and A1C level

Gastroparesis: Post-surgical gastroparesis (Part Four)

  • Surgery is a common trigger for GP
  • Surgeries that manipulate the stomach are more associated with GP, like gastrectomy, fundoplication or weight loss surgery
  • Gastric inflammation associated with surgery inhibits GI motility
  • 7.2% of GP cases occur after gastrectomy or fundoplication
  • Nissen fundoplication is the most common cause of post-surgical GP
  • A follow up surgery after Nissen fundoplication can sometimes reverse GP
  • Surgeries that don’t manipulate the stomach can also cause GP, like removal of esophagus, lung transplant, and liver surgery

Gastroparesis: Less common causes (Part Five)

  • Parkinson disease, multiple sclerosis, muscular dystrophy, myopathy, scleroderma, Sjogrens, polymyositis and stroke can all cause GP.
  • 10.8% of GP cases are associated with connective tissue disorder
  • Pseudo obstruction syndromes and autonomic neuropathy can occur concurrently with GP
  • Viral infections can cause acute GP that usually resolves within a year
  • Spinal cord injury, hypothyroidism, hyperparathyroidism, Addison’s disease and use of opiates or anticholinergics can contribute to GP
  • GP occurs disproportionately in people who have had their gallbladders removed
    • Often, GP does not immediately follow gallbladder removal but can present months or years later
    • Gallbladder removal is also associated with conditions that can occur with GP such as chronic fatigue syndrome, fibromyalgia, depression and anxiety
    • GP patients who have had gallbladders removed are usually older women who are overweight despite not coming enough calories