Gastroparesis Diagnosis Gastroparesis Diagnosis and Treatment and Treatment

Bill Richards, MD Bill Richards, MD FACSFACS

Professor and Professor and Chair SurgeryChair Surgery

University of South University of South AlabamaAlabama

College of College of MedicineMedicine

Anatomical and Functional Anatomical and Functional regions of the Stomachregions of the Stomach

Migrating Motor Migrating Motor ComplexComplex

Etiology of GastroparesisEtiology of Gastroparesis Diabetes-relatedDiabetes-related Metabolic hyper-glycemia, hypo-kalemia, Metabolic hyper-glycemia, hypo-kalemia,

hypermagnesemia hypermagnesemia Hypo-pituitarism, hypo-adrenalism, hypo-thyroidismHypo-pituitarism, hypo-adrenalism, hypo-thyroidism Chronic renal failureChronic renal failure Portal hypertensionPortal hypertension Intra-abdominal malignancyIntra-abdominal malignancy Infectious: H. pylori., EBVInfectious: H. pylori., EBV Rheumatological: Systemic sclerosis, SLE, Rheumatological: Systemic sclerosis, SLE, Myotonic dystrophiesMyotonic dystrophies Central Nervous System disorders (Parkinson’s disease, Central Nervous System disorders (Parkinson’s disease,

multiple sclerosis)multiple sclerosis) Peripheral Nervous System disorders (amyloid neuropathy, Peripheral Nervous System disorders (amyloid neuropathy,

Guillain-Barre, primary dysautonomia)Guillain-Barre, primary dysautonomia) Psychiatric disorders (anorexia nervosa, rumination Psychiatric disorders (anorexia nervosa, rumination

syndrome)syndrome)

Surgery Related Etiology of Surgery Related Etiology of GastroparesisGastroparesis

Vagotomy, Vagotomy, Duodenectomy Duodenectomy Mechanical Obstruction Partial Mechanical Obstruction Partial

Drugs that delay Gastric Drugs that delay Gastric EmptyingEmptying

AlcoholAlcohol Aluminium hydroxide antacidsAluminium hydroxide antacids AtropineAtropine beta-Agonistsbeta-Agonists Calcium channel blockersCalcium channel blockers DiphenhydramineDiphenhydramine L-DopaL-Dopa LithiumLithium OndansetronOndansetron OpiatesOpiates PhenothiazinesPhenothiazines Tricyclic anti-depressantsTricyclic anti-depressants

Gastric Inhibitory Gastric Inhibitory HormonesHormones

Inhibitory Hormone Stimulation Site of Secretion Other Actions

Cholecystokinin fat and protein in small bowel Duodenum jejunum Gastric relaxation, sensation of fullness

Glucagon Hypoglycemia, amino acids, beta-adrenergic stimulation

pancreas (alpha cells) Slows MMC

Glucagon-like peptide-1

Increased glucose, fatty acids and amino acids

Distal Small intestine and colon

decreases appetite

Peptide YY Increased glucose, fatty acids and amino acids

Terminal ileum and colon

decreases appetite

Secretin Acid, lipid or bile in duodenal lumen

Duodenum (D Cells) Acts indirectly via inhibition of gastrin release

Somatostatin Acidification of duodenal lumen Gastric antrum (D cells)

Induces Fasting Small Intestinal activity

Gastric Stimulatory Gastric Stimulatory Hormones Hormones

Table 1. Hormonal influences of gastric motility

Stimulatory Hormone Stimulation Site of Secretion Other Actions

Gastrin Gastric pH>3, vagus nerve, antral distention, protein, calcium, alcohol

Gastric antrum (G cells) Inhibits small bowel and colonic motility

Ghrelin Fasting Gastric fundus Stimulates hunger

Motilin Acid and vagus nerve Stomach and duodenum (M Cells)

Induces phase 3 MMC peristalsis

Anti-emetic agentsAnti-emetic agents

Prochlorperazine CompazineProchlorperazine Compazine Tardive dyskinesiaTardive dyskinesia

PromethazinePromethazine 5-hydroxytryptamine receptor 5-hydroxytryptamine receptor

agonist (i.e. odansetron)agonist (i.e. odansetron) Reduce dose with hepatic diseaseReduce dose with hepatic disease

Botulinum Toxin A for the Treatment of Botulinum Toxin A for the Treatment of Delayed Gastric EmptyingDelayed Gastric Emptying

Am J Gastro 103; 416-423, 2008 Am J Gastro 103; 416-423, 2008

Within Group  

  Botulinum Toxin Placebo

Improved (%)* 37.5%   56.3%  

% Gastric retention†

 2 h -16.3+ 22.9 -10.8+ 20.6

Placebo and Botox improved symptoms and gastric emptying

Prokinetic agentsProkinetic agents Metoclopramide (reglan)Metoclopramide (reglan)

Antral contractionsAntral contractions Extrapyramidal symptomsExtrapyramidal symptoms

Erythromycin Erythromycin Motolin agonistMotolin agonist Induces phase III MMCInduces phase III MMC Cardiac arrhythmiasCardiac arrhythmias

Domperidone. Domperidone. Not marketed in USNot marketed in US

Cisapride Cisapride cardiac arrhythmias FDA removed from usecardiac arrhythmias FDA removed from use

Enterra NeurostimulatorEnterra Neurostimulator

Predictive Factors for Clinical Improvement Predictive Factors for Clinical Improvement with Enterra Gastric Electric Stimulation with Enterra Gastric Electric Stimulation

Treatment for Refractory Gastroparesis Treatment for Refractory Gastroparesis Dig Dig Dis Sci (2008) 53:2072–2078Dis Sci (2008) 53:2072–2078

ImproveImproved N=14d N=14

Same Same

N=8N=8Worse Worse

N=6N=6

AgeAge 4545 3333 3838

Female %Female % 71%71% 100%100% 100%100%

% diabetic% diabetic 50%50% 60%60% 33%33%

Use narcoticsUse narcotics 29%29% 75%75% 50%50%

Gastric Gastric emptying emptying

% retention at 4 % retention at 4 HH

72%72% 54%54% 71%71%

Ileal BrakeIleal Brake

Ileal brake is most Ileal brake is most potent inhibitory potent inhibitory feedbackfeedback

Companion brakes Companion brakes work in absence of work in absence of ileal brakeileal brake

Ileal BrakeIleal Brake

Fats in ileum Fats in ileum trigger release of trigger release of Peptide YYPeptide YY

Peptide YY inhibits Peptide YY inhibits gastric emptying gastric emptying

Resectional Therapy Resectional Therapy

Subtotal Subtotal gastrectomy gastrectomy

Roux-en-Y Roux-en-Y reconstructionreconstruction

Preop Preop measurement of measurement of vitamin D, vitamin D, Thiamine,Thiamine,

B-12, folate, ironB-12, folate, iron