Management Of Gastroparesis
Michael Camilleri, MD1, Henry P. Parkman, MD2, Mehnaz A. Shafi, MD3, Thomas L. Abell, MD4 and Lauren Gerson, MD, MSc5 1Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA; 2Temple University, Philadelphia, Pennsylvania, USA; 3University of Texas, MD Anderson Cancer Center, Houston, Texas, USA; 4University of Mississippi, Jackson, Mississippi, USA; 5Stanford University, Palo Alto, California, USA Am J Gastroenterol2013; 108:1837; doi:10.1038/ajg.2012.373; published online 13 November 2012 Received 24 May 2012; accepted 5 October 2012 Correspondence: Michael Camilleri, Department of Gastroenterology, Mayo Clinic, 200 First Street SW, Charlton 8-110, Rochester, Minnesota 55905, USA. E-mail: [email protected] This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do no Continue reading >>
Gastroparesis - Topic Overview
After a meal, the stomach normally empties in 1½ to 2 hours. When you have gastroparesis, your stomach takes a lot longer to empty. The delay results in bothersome and possibly serious symptoms because digestion is altered. Bezoar is a fairly rare condition related to gastroparesis. In this condition, food stays in the stomach for a long time and forms a hard lump. This causes food to get stuck in the stomach. Gastroparesis occurs when the nerves to the stomach are damaged or don't work. Diabetes is the most common cause. Other causes include some disorders of the nervous system, such as Parkinson's disease and stroke, and some medicines, such as tricyclic antidepressants, calcium channel blockers, and opiate pain relievers. This condition can also be a complication of gastric surgery. The most common symptoms of gastroparesis are: A feeling of fullness after only a few bites of food. Nausea. Food coming back up your throat, without nausea or vomiting. Gastroparesis may be suspected in a person with diabetes who has upper digestive tract symptoms or has blood sugar levels that are hard to control. Controlling blood sugar levels may reduce symptoms of gastroparesis. Your doctor will ask you questions about your symptoms and will do a physical exam. He or she may also need to do tests to check your stomach and digestion and to rule out other problems that may be causing your symptoms. Tests that may be done include: Gastric emptying scan. This test can show how quickly food leaves your stomach. A radioactive substance is included in a solid meal that you eat. It does not include enough radiation to harm you. This substance shows up on a special image, allowing a doctor to see food in your stomach and watch how quickly it leaves your stomach. Gastric or duodenal manometry Continue reading >>
Clinical Guideline: Management Of Gastroparesis
Benefits/Harms of Implementing the Guideline Recommendations Appropriate management of patients with gastroparesis to improve outcomes The FDA placed a black-box warning on metoclopramide because of the risk of side effects, including tardive dyskinesia. Complications of enteral nutrition include infection, tube migration, and dislodgement. With enteral nutrition, there is a theoretical risk of increased pulmonary aspiration in patients with weak lower esophageal sphincter; hence, it is advisable that the feeding tube should be placed well beyond the angle of Treitz in such patients. Complications from gastric electrical stimulation (GES) such as local infection or lead migration, as well as complications related to the surgery may occur in up to 10% of patients implanted. The risk of malnutrition and weight loss following gastrectomy has to be weighed relative to the symptom relief. Metoclopramide is the first line of prokinetic therapy and should be administered at the lowest effective dose. The risk of tardive dyskinesia has been estimated to be < 1%. Patients should be instructed to discontinue therapy if they develop side effects including involuntary movements. Several US medical centers have recently placed several additional restrictions on promethazine, related to concerns about sedation, possible cardiac toxicity (corrected QT prolongation), damage to peripheral veins, and lack of availability of the drug. The synthetic cannabinoid, dronabinol, carries the risk of hyperemesis on withdrawal, and optimum treatment strategies are unclear. Rating Scheme for the Strength of the Recommendations The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to grade the strength of recommendations. The strength of a recommendation was Continue reading >>
Gastroparesis In Adults: Oral Erythromycin
Gastroparesis in adults: oral erythromycin The content of this evidence summary was up-to-date in June 2013 . See summaries of product characteristics (SPCs), British national formulary (BNF) or the MHRA or NICE websites for up-to-date information. Only 1small single-blind, crossover study (n=13) identified in a systematic review (5 studies, varying designs, n = 60) found a statistically significant benefit for erythromycin in the short term for improving symptoms of gastroparesis compared with metoclopramide. The other studies identified in the systematic review did not provide reliable evidence of the effectiveness, safety and tolerability of erythromycin for gastroparesis in either the short or longer term. Regulatory status: Off-label for treating symptoms of gastroparesis. Fivesmall studies (n=60), 4of which reported on symptoms as an outcome. Only 1study found a statistically significant benefit of oral erythromycin on symptoms compared with metoclopramide. Another controlled study found no benefit compared with placebo. Two uncontrolled studies found no benefit compared with baseline symptoms. Can rarely cause serious adverse effects such as hearing loss, allergic reactions, skin reactions, hepatic dysfunction and cardiac arrhythmias. Is associated with many drug interactions. Is contraindicated in people with known hypersensitivity, and in those taking astemizole, terfenadine, cisapride, pimozide, ergotamine, dihydroergotamine and simvastatin. Gastrointestinal adverse effects, including nausea, vomiting, diarrhoea and abdominal pain, are common with erythromycin. Erythromycin is available in various strengths and formulations with costs ranging from 1.91 to 12.70 for 28capsules or tablets. Erythromycin is a macrolide antibiotic that is licensed for treating and Continue reading >>
Medications
What can be done when Treatments don't Seem to Help Medications are used to try to help reduce symptoms of gastroparesis. The drug categories commonly used are prokinetic (promotility) agents and antiemetic agents. There is a lack of evidence-based information about what drugs work best for patients with gastroparesis. Drugs are often prescribed off-label by doctors, based on their clinical experience and how the drugs treat similar symptoms in other conditions. Only one drug, metoclopramide, is approved by the U.S. Food and Drug Administration (FDA) for the treatment of gastroparesis. Off-label use is the permissible practice by doctors to prescribe medications for other than their FDA approved intended indications. Prokinetic, or promotility, agents directly help the stomach empty more quickly and may improve symptoms such as nausea, vomiting, and bloating. Metoclopramide, a dopamine antagonist, has been available since 1983. It is the only FDA approved medication that improves stomach emptying. Multiple clinical trials show that it improves symptoms in about 40% of patients. Intolerable side effects are common and 2040% of patients cannot take this drug. The most bothersome side effect, tardive dyskinesia, is a rare but serious movement disorder that is often irreversible. The risk of developing tardive dyskinesia increases with the duration of treatment and the total cumulative dose. Treatment with metoclopramide for longer than 12 weeks should be avoided in all but rare cases where therapeutic benefit is thought to outweigh the risk of developing tardive dyskinesia. ( More information at this FDA page ) Domperidone, a peripheral dopamine antagonist, is a prokinetic agent that has never been approved by the FDA. It is similar in effectiveness to metoclopramide, but Continue reading >>
Gastroparesis
APPs: Enhance your delivery of patient care Digestive Disease Week (DDW) is the premier meeting for the GI professional. Every year it attracts approximately 15,000 physicians, researchers and academics from around the world who desire to stay up-to-date in the field. 2018 Research Grants Open for Applications Don't lose sight of award deadlines during the busy holiday season. Read on to discover open grants from the AGA Research Foundation and when applications are due. Take your new research project idea and make it a reality with an AGA research award. Eight grants are open with a Jan. 12, 2018, deadline. Gastroparesis Treatment: The Future is Bright A Selection of the Best AGA Abstracts of DDW 2017 Watch Session Highlights on Neurogastroenterology & Motility at DDW 2017 Whether you missed or want to re-watch the best science and cutting-edge research in neurogastroenterology and GI motility, top session highlights are now available. Challenges and Emerging Solutions in Upper GI Disorders Drs. Colin Howden and Nimish Vakil (pictured) debrief on the AGA Drug Development Conference in the March issue of Gastro. 2017 AGA Postgraduate Course Features 29 Breakout Sessions Step beyond basic learning in six general sessions, plus your choice of one luncheon breakout and one case-based session. Treating Upper GI Diseases: Where Do We Go from Here? This was the overarching question at our recent Drug Development Conference. Read a meeting summary in GI & Hep News. The AGA Institute Council section nomination site is now open for 2017-2019 vice chairs and nominating committees. Dr. Colin Howden discusses the highs and lows of drug development for gastroesophageal reflux disease in a new blog post. Gastroparesis Treatment: Whats Coming Up Next Dr. William Hasler discusses the Continue reading >>
Gastroparesis
Gastroparesis is a disease of the muscles of the stomach or the nerves controlling the muscles that causes the muscles to stop working. Gastroparesis results in inadequate grinding of food by the stomach, and poor emptying of food from the stomach into the intestine. The primary symptoms of gastroparesis are nausea, vomiting, and abdominal pain. Gastroparesis is best diagnosed by a test called agastric emptying study. Gastroparesis usually is treated with nutritional support, drugs for treating nausea and vomiting, drugs that stimulate the muscle to contract, and, less often, electrical pacing, and surgery. What is gastroparesis? Gastroparesis means weakness of the muscles of the stomach. Gastroparesis results in poor grinding of food in the stomach into small particles and slow emptying of food from the stomach into the small intestine. The stomach is a hollow organ composed primarily of muscle. Solid food that has been swallowed is stored in the stomach while it is ground into tiny pieces by the constant churning generated by rhythmic contractions of the stomach's muscles. Smaller particles are digested better in the small intestine than larger particles, and only food that has been ground into small particles is emptied from the stomach and well digested. Liquid food does not require grinding. The ground solid and liquid food is emptied from the stomach into the small intestine slowly in a metered fashion. The metering process allows the emptied food to be well-mixed with the digestive juices of the small intestine, pancreas, and liver (bile) and to be absorbed well from the intestine. The metering process by which solid and liquid foods are emptied from the stomach is a result of a combination of relaxation of the muscle in parts of the stomach designed to accommoda Continue reading >>
Diabetic Gastroparesis
stomach , diabetes mellitus , dyspepsia , vomiting , abdominal pain , diabetic complications , gastric emptying Gastroparesis is a serious complication of diabetes mellitus (DM), defined as a delay in gastric emptying without any mechanical obstruction in the stomach. Other non-diabetic causes of gastroparesis are surgery, neurologic disorders, medication and idiopathic causes; 1 however, the outcomes for those with diabetic gastroparesis (DGP) are worse. 2 This disorder causes a huge morbidity burden as well as significantly impairing glucose control. In recent years, we have gained much insight into the pathophysiology of DGP, in addition to increased awareness of the disorder. However, different pathophysiologic mechanisms and variable response to treatments make it still difficult to optimize therapy. Population-based data on DGP are limited. In case series from tertiary care centers, delayed gastric emptying is reported in one-third of diabetic patients with an equal prevalence in type 1 and type 2 diabetes. However, at the population level, only 5% of type 1 and 1% of type 2 patients have a combination of delay in gastric emptying and presence of typical symptoms consistent with DGP. 1 Gastroparesis typically develops after at least 10 years of diabetes, and these patients generally have evidence of autonomic dysfunction. 3 , 4 The disease affects females more than males in an approximate 4:1 ratio and typically presents in the fourth or fifth decades in the type 1 diabetic population. 2 One possible explanation for this gender difference is the fact that emptying in females is on average slower than in males. 5 , 6 But, recent animal data suggest that the effect of diabetes on the enteric nervous system (ENS) is more pronounced in the female sex, which could be Continue reading >>
A Review Of Diabetic Gastroparesis For The Community Pharmacist
A Review of Diabetic Gastroparesis for the Community Pharmacist Michelle E. Leatherwood, PharmD Candidate Samford University McWhorter School of Pharmacy Samford University McWhorter School of Pharmacy Samford University McWhorter School of Pharmacy ABSTRACT: Over 29.1 million people in United States have diabetes and are faced with the complications associated with the disease. Diabetes is the most common systemic disease that causes gastroparesis. Diabetic gastroparesis is commonly suspected in poorly controlled diabetic patients who present with gastrointestinal complaints, especially following a meal. Once a diagnosis is made, management of the condition is centered on optimizing blood glucose control, providing nutritional support including hydration, and in many cases using prokinetic and antiemetic medications. As healthcare providers, community pharmacists are in key positions to assist patients in how to manage this irreversible complication of diabetes. Approximately 9.3% of the U.S. population has diabetes.1 This equates to about 29.1 million people who could be visiting community pharmacies for diabetes medications and supplies.2 Diabetic patients may also seek pharmacists for education and advice on how best to maintain blood glucose control in hopes of avoiding complications such as cardio-vascular disease, stroke, nephropathy, and retinopathy. Among the many complications, diabetes is the most common systemic disease that causes gastroparesis.3 Diabetic gastroparesis is an autonomic neuropathic complication of diabetes not due to a mechanical gastrointestinal (GI) obstruction.4 Uncontrolled elevations of blood glucose over a long period of time can damage nerves in the enteric nervous system, which governs the GI system.5,6 Subsequently, the stomach and Continue reading >>
Gastroparesis
Gastroparesis Today’s Dietitian Vol. 16 No. 7 P. 16 Dietitians play an important role in its treatment and management. Gastroparesis, or delayed gastric emptying, is a condition in which the stomach takes longer than it should to pass its contents to the small intestine. This “stomach paralysis” results in a host of uncomfortable symptoms that can greatly reduce the quality of life for its sufferers. Signs and Symptoms Symptoms of gastroparesis can range from mild to severe, depending on the individual. The most common include nausea, vomiting, and early satiety. Since food doesn’t move through the stomach at a normal pace, many patients report feeling full and bloated after eating. The feeling of fullness can result in inadequate food intake, which can lead to malnutrition and vitamin and mineral deficiencies. “The nausea and vomiting in some patients is so severe that they really have to work hard to get enough nutrition,” says Marcia Nahikian-Nelms, PhD, RDN, LD, CNSC, a clinical professor and the director of the dietetic internship program at Ohio State University. Moreover, food that remains in the stomach for extended periods of time can ferment and cause bacterial overgrowth. Subsequently, the food can harden into masses called bezoars, which cause nausea and vomiting and can lead to a stomach obstruction, according to the American College of Gastroenterology. In some cases, the bezoars can block food’s passageway into the small intestine.1 Causes Many conditions can cause gastroparesis, but diabetes is one of the most common etiologies. Neuropathy, which is a diabetes complication, can damage the vagus nerve, one of the primary autonomic controls for gastric emptying, Nahikian-Nelms says. Hyperglycemia also can cause delays in gastric emptying, whi Continue reading >>
Diabetes Mellitus: Management Of Gastrointestinal Complications
Diabetes Mellitus: Management of Gastrointestinal Complications BETH CAREYVA, MD, and BRIAN STELLO, MD, Lehigh Valley Health Network/University of South Florida Morsani School of Medicine, Allentown, Pennsylvania Am Fam Physician.2016Dec15;94(12):980-986. Gastrointestinal disorders are common complications of diabetes mellitus and include gastroparesis, nonalcoholic fatty liver disease, gastroesophageal reflux disease, and chronic diarrhea. Symptoms of gastroparesis include early satiety, postprandial fullness, nausea, vomiting of undigested food, bloating, and abdominal pain. Gastroparesis is diagnosed based on clinical symptoms and a delay in gastric emptying in the absence of mechanical obstruction. Gastric emptying scintigraphy is the preferred diagnostic test. Treatment involves glucose control, dietary changes, and prokinetic medications when needed. Nonalcoholic fatty liver disease and its more severe variant, nonalcoholic steatohepatitis, are becoming increasingly prevalent in persons with diabetes. Screening for nonalcoholic fatty liver disease is not recommended, and most cases are diagnosed when steatosis is found incidentally on imaging or from liver function testing followed by diagnostic ultrasonography. Liver biopsy is the preferred diagnostic test for nonalcoholic steatohepatitis. Clinical scoring systems are being developed that, when used in conjunction with less invasive imaging, can more accurately predict which patients have severe fibrosis requiring biopsy. Treatment of nonalcoholic fatty liver disease involves weight loss and improved glycemic control; no medications have been approved for treatment of this condition. Diabetes is also a risk factor for gastroesophageal reflux disease. Patients may be asymptomatic or present with atypical symptoms Continue reading >>
- Role of the Gastrointestinal Tract Microbiome in the Pathophysiology of Diabetes Mellitus
- Diabetes management 3: the pathogenesis and management of diabetic foot ulcers
- Women in India with Gestational Diabetes Mellitus Strategy (WINGS): Methodology and development of model of care for gestational diabetes mellitus (WINGS 4)
Clinical Guideline: Management Of Gastroparesis.
Clinical guideline: management of gastroparesis. Eating disorder, unspecified (307.50), Esophageal reflux (530.81), Gastroparesis (536.3), Neurologic examination (89.13), Open and other partial gastrectomy (43.89), Unspecified acquired hypothyroidism (244.9) Acupuncture Therapy , Antidepressive Agents, Tricyclic , Antiemetics , Autoimmune Diseases , Botulinum Toxins , Breath Tests , Complementary Therapies , Counseling , Diabetes Mellitus , Diagnosis, Differential , Digestive System Surgical Procedures , Domperidone , Electric Stimulation Therapy , Electrolytes , Enteral Nutrition , Erythromycin , Fluid Therapy , Gastrectomy , Gastric Emptying , Gastroesophageal Reflux , Gastroparesis , Gastrostomy , Hypothyroidism , Jejunostomy , Medical History Taking , Metoclopramide , Neurologic Examination , Nutritional Support , Radionuclide Imaging , Thyroid Function Tests acupuncture , domperidone , erythromycin , hypothyroidism , nutritional support , radionuclide imaging National Guideline Clearinghouse (NGC). Guideline summary: Clinical guideline: management of gastroparesis. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013 Jan 01. [cited 2018 Mar 30]. Available: Definitions of the quality of evidence (High, Moderate, Low, Very low) and strength of recommendations (Strong and Conditional) are provided at the end of the "Major Recommendations" field. Definition of Gastroparesis Syndrome and Gastroparesis Symptoms The diagnosis of gastroparesis is based on the combination of symptoms of gastroparesis, absence of gastric outlet obstruction or ulceration, and delay in gastric emptying. (Strong recommendation, high level of evidence) Accelerated gastric emptying and functional dyspepsia can present with Continue reading >>
Gastroparesis: New Guidelines
This feature requires the newest version of Flash. You can download it here . Hello. I'm Dr. David Johnson. Welcome back to another installment of GI Common Concerns -- Computer Consult. Today I want to discuss gastroparesis, because this is a fairly pragmatic conversation that I frequently have with patients. Someone comes in every day with abdominal pain, bloating, nausea, and early satiety. A variety of symptoms raise the possibility of gastroparesis. The American College of Gastroenterology[ 1 ] recently published some very practical, updated guidelines on gastroparesis. I thought it would be helpful to review some of these recommendations and put into perspective how you can apply them to your patients who you think might have a gastroparetic condition. The definition of gastroparesis is a patient with evidence of delayed gastric emptying but no evidence of an outlet obstruction. The clinical spectrum can overlap with conditions such as functional dyspepsia or accelerated gastric emptying. The symptoms and the findings must correlate with objective evidence based on diagnostic testing. Gastroparesis is a very common condition. It is prevalent in postsurgical patients, particularly after fundoplication. I see many of these patients in my practice. There are also idiopathic cases -- the patients for whom we don't have an explanation. Identifiable causes should be sought in every patient in whom you suspect a gastroparetic condition. The differential should include diabetes because it is prevalent in these patients. In community settings, 5% of patients with type 1 diabetes, 1% of patients with type 2 diabetes, and about 0.2% of nondiabetics have gastroparesis. The writing committee for the American College of Gastroenterology recommends taking a good history, becaus Continue reading >>
Diagnosis
Print Doctors use several tests to help diagnose gastroparesis and rule out conditions that may cause similar symptoms. Tests may include: Gastric emptying study. This is the most important test used in making a diagnosis of gastroparesis. It involves eating a light meal, such as eggs and toast, that contains a small amount of radioactive material. A scanner that detects the movement of the radioactive material is placed over your abdomen to monitor the rate at which food leaves your stomach. You'll need to stop taking any medications that could slow gastric emptying. Ask your doctor if any of your medications might slow your digestion. Upper gastrointestinal (GI) endoscopy. This procedure is used to visually examine your upper digestive system — your esophagus, stomach and beginning of the small intestine (duodenum) — with a tiny camera on the end of a long, flexible tube.This test can also diagnose other conditions, such as peptic ulcer disease or pyloric stenosis, which can have symptoms similar to those of gastroparesis. Ultrasound. This test uses high-frequency sound waves to produce images of structures within your body. Ultrasound can help diagnose whether problems with your gallbladder or your kidneys could be causing your symptoms. Upper gastrointestinal series. This is a series of X-rays in which you drink a white, chalky liquid (barium) that coats the digestive system to help abnormalities show up. Treatment Treating gastroparesis begins with identifying and treating the underlying condition. If diabetes is causing your gastroparesis, your doctor can work with you to help you control it. Changes to your diet Maintaining adequate nutrition is the most important goal in the treatment of gastroparesis. Many people can manage gastroparesis with diet changes a Continue reading >>
Management Of Diabetic Gastroparesis Aljarallah Bm - Saudi J Gastroenterol
Symptoms suggestive of gastroparesis occur in 5% to 12% of patients with diabetes. Such a complication can affect both prognosis and management of the diabetes; therefore, practicing clinicians are challenged by the complex management of such cases. Gastroparesis is a disorder characterized by a delay in gastric emptying after a meal in the absence of a mechanical gastric outlet obstruction. This article is an evidence-based overview of current management strategies for diabetic gastroparesis. The cardinal symptoms of diabetic gastroparesis are nausea and vomiting. Gastroesophageal scintiscanning at 15-minute intervals for 4 hours after food intake is considered the gold standard for measuring gastric emptying. Retention of more than 10% of the meal after 4 hours is considered an abnormal result, for which a multidisciplinary management approach is required. Treatment should be tailored according to the severity of gastroparesis, and 25% to 68% of symptoms are controlled by prokinetic agents. Commonly prescribed prokinetics include metoclopramide, domperidone, and erythromycin. In addition, gastric electrical stimulation has been shown to improve symptoms, reduce hospitalizations, reduce the need for nutritional support, and improve quality of life in several open-label studies. Keywords:Diabetes, gastroparesis, vomiting, gastric emptying, insulin, glucose Aljarallah BM. Management of diabetic gastroparesis. Saudi J Gastroenterol 2011;17:97-104 Aljarallah BM. Management of diabetic gastroparesis. Saudi J Gastroenterol [serial online] 2011 [cited2018 Mar 31];17:97-104. Available from: Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction of the stomach in patients with diabetes. [1] The cardinal symptoms include p Continue reading >>
