Symptoms of Gastroparesis

• Nausea
• Vomiting
• Abdominal bloating
• Abdominal pain
• Early satiety
• Heartburn or gastroesophageal reflux disease (GERD)
• Changes in blood sugar levels
• Lack of appetite
• Excessive weight loss/gain

Diagnosing Gastroparesis

Gastroparesis is difficult to diagnose because it has many causes, and most of the symptoms are subjective. Since nausea, vomiting, fullness, and pain are not very measurable, they make gastroparesis hard to classify by severity. The most common way to diagnose gastroparesis is as follows:

• Doctors must rule out other causes of the symptoms like a bowel obstruction, sphincter of oddi dysfunction, Celiac Sprue, and Irritable Bowel Syndrome. After doctors have determined that nothing else is the cause of the problem, they should perform a gastric emptying test, the most popular of which is a Scintigraphy.

• Nuclear Scintigraphy usually involves eating an egg meal made with a nuclear isotope. This isotope is followed by the technicians to see how much of the egg meal empties over a four hour period. A percentage is then assigned to the amount that is pushed through the stomach over the four hours. Anything that is less than 90% emptying over four hours is considered positive for gastroparesis.

Types of Gastroparesis

Diabetic

Diabetes is the largest known cause of chronic gastroparesis. It is not entirely known why diabetes can cause gastroparesis, but studies have suggested that a lack of glycemic control plays a part.It is believed that the lack of glycemic control causes nerves in the stomach to die and that once dead the stomach stops functioning.

One of the first treatments for diabetic gastroparesis is helping the patient obtain glycemic control.

Post-Surgical

This can be seen after any surgical procedure on the abdomen, often times unrelated to surgery on the stomach. Long term prognosis is unknown for this type of gastroparesis. Spontaneous resolution has been seen in some patients with post-surgicalgastroparesis.

Postvagotomy

A vagotomy is where the surgeon cuts the Vagus nerve, a nerve that connects to the stomach. This is intentionally done to help those with peptic ulcer disease in some cases and is sometimes inadvertently done in other abdominal surgeries. It is not likely for this to cause gastroparesis but it does sometimes because communication between the stomach and the brain is impaired.

Antireflux Surgery

A nissen fundoplication currently seems to be the leading cause of gastroparesis in postsurgical cases. A nissen fundoplication is done to alleviate reflux but can cause gastroparesis in one of two ways. The first is by cutting some or all of the Vagus nerve (refer to Postvagotomy) and the second is the nissen fundoplication is thought to aggravate underlying stomach dysmotility causing the problem to start.

Heart/Lung Transplant

After a single lung transplant around 25% of patients develop gastroparesis while up to 80% can develop it with both a heart and a lung transplant. There are many suspected reasons like vagal nerve dysfunction, infection, and the immunosuppressant.

Idiopathic Gastroparesis

Idiopathic Gastroparesis is gastroparesis that has no identifiable cause.

Other Causes

• Medications (Most Often Narcotics)
• Connective Tissue Disorders
• Malignant Tumors
• Chemo and Stem Cell Transplants
• Autoimmune and Paraneoplastic
• Celiac Plexus Injury
• Viral Infections
• Neurologic Disorders
• Psychiatric Disease
• Chronic Pancreatitis
• Renal Failure
• TPN

Treatment of Gastroparesis

There is no cure for gastroparesis but there are treatment options that can control the symptoms of chronic vomiting and nausea. Often, multiple therapies are used in combination*. An overview of care for gastroparesis includes:

• Diet Modification
• Prokinetic Drugs
• Antiemetic Drugs
• Enterra Therapy
• Pyloroplasty
• Enteral Nutrition
• Gastrectomy

Dietary Changes

The first treatment for gastroparesis is changing the dietary pattern of the patient. Some changes that can be made to help improve gastric symptoms are smaller meals, increased liquids, softer solids, decreased fat, and less fiber. Basically, we are trying to find foods which are not affected by reduced gastric motility.
Your physician and dietician should also be finding foods to help you prevent weight gain which is very common in the early stages of gastroparesis.
Because of the nature of the disease, patients with gastroparesis are prone to malnutrition. Gastroparesis often causes the body to not absorb enough iron, calcium, Vitamin D, and Vitamin B12. Your health care provider should do a nutrition assessment in order to find your risk for malnutrition and recommend action from there. Almost all gastroparesis patients should be taking vitamin supplementation.

Prokinetic Treatments

Prokinetic drugs are designed to help treat what is believed to be the underlying cause of gastroparesis, the delayed gastric emptying. There are many kinds of prokinetic drugs; however, they all work by blocking a specific hormone in order to increase gastric motility or cause contractions. Although there has not been significant evidence to show a correlation between the speed of gastric emptying and the severity of side effects, prokinetic treatment has been useful in treating gastroparesis in some people.

Antiemetic

Antiemetic drugs are a classification of drugs which seek to reduce nausea and vomiting in patients. Antiemetic drug treatment targets the symptoms of gastroparesis instead of the believed underlying cause, delayed gastric emptying, because of the lack of association between delayed gastric emptying and symptoms. Antiemetics are often used in conjunction with prokinetics to relieve nausea and speed gastric emptying.

Gastric Electrical Stimulation Therapy

Gastric Electrical Stimulation has many methods of action. Most notably the antiemetic effect on the symptoms of Nausea and Vomiting. The electrical stimulation of Enterra Therapy normalizes signals from the stomach to the brain via the vagal nerve. Resulting in a significant reduction in the symptoms of Nausea and Vomiting.

Electrical stimulation therapy also has prokinetic effects, which increases rate of gastric emptying.  Instead of blocking hormone receptors in the body like medication does, electrical stimulation therapy provides electrical pulses in the gut to cause the muscle to contract. A device is surgically implanted and is supposed to act like a pacemaker for the GI tract.

Enterra Therapy

This is a type of electrical stimulation therapy that uses a system of short pulses of electricity from an implanted device. Studies have shown decreases in GI symptoms, hospitalizations, prokinetic usage, and medical costs for those using Enterra therapy. It also shows an increase in nutrition and quality of life in mainly diabetic, idiopathic, postsurgical, and medication related gastroparesis. This is probably due to the remarkable decrease in nausea/vomiting in patients receiving the treatment. One study reported reduction of nausea/vomiting by 68-87%  at 12 months. Enterra therapy is thought to work by stimulating the vagus nerve which is responsible for GI control among other things. This type of therapy has not been shown to help with gastric dysrhythmia as the pulses are not as long as the body’s normal gastric pulses. {See video below for details}

Pyloroplasty

Pyloroplasty is surgery to widen the pylorus. This is an opening near the end of the stomach that allows food to flow into the duodenum, the first part of the small intestine.

The pylorus is surrounded by a pyloric sphincter, a thick band of smooth muscle that causes it to open and close at certain stages of digestion. The pylorus normally narrows to about 1 inch in diameter. When the pyloric opening is unusually narrow or blocked, it’s hard for food to pass through. This leads to symptoms like indigestion and constipation.

Pyloroplasty involves cutting through and removing some of the pyloric sphincter to widen and relax the pylorus. This makes it easier for food to pass through the stomach. In some cases, the pyloric sphincter is entirely removed.

How we treat gastroparesis

In order to treat gastroparesis many things must be taken into consideration. It is important to consider the most prominent symptoms, how long the patient has had the disease, and etiology of the disease in order to determine how to treat each patient. Come see us and we will formulate the best way to treat your gastroparesis.