Management of Gastroparesis - Mucosal Immunology · Management of Gastroparesis ... but consensus...
Transcript of Management of Gastroparesis - Mucosal Immunology · Management of Gastroparesis ... but consensus...
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Management of Gastroparesis
Bible Class
Jan Hendrik Niess
As published in Am J Gastroenterol. 2013 Jan;108(1):18-37
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What is the definition of gastroparesis?
What are cardinal symptoms of gastroparesis?
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What is the definition of gastroparesis?
Gastroparesis is defined as a syndrome of objectively delayed emptying in the
absence of mechanical obstruction.
What are cardinal symptoms of gastroparesis?
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What is the definition of gastroparesis?
Gastroparesis is defined as a syndrome of objectively delayed emptying in the
absence of mechanical obstruction.
What are cardinal symptoms of gastroparesis?
• early satiety
• postprandial fullness
• Nausea
• vomiting
• bloating
• upper abdominal pain
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What is the definition of gastroparesis?
Gastroparesis is defined as a syndrome of objectively delayed emptying in the
absence of mechanical obstruction.
What are cardinal symptoms of gastroparesis?
• early satiety
• postprandial fullness
• Nausea
• vomiting
• bloating
• upper abdominal pain
Problem: functional dyspepsia and accelerated gastric emptying can present
with similar symptoms
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How can be tested for delayed gastric emptying?
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How can be tested for delayed gastric emptying?
Euglycamia, avoid medication that delays or accelerates gastric emptying
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How can be tested for delayed gastric emptying?
1. Gastric emptying scintigraphy
Ingestion of a solid meal to which a radiotracer is bound (usually radiolabel egg
Albumen with Tc-99m sulfur colloid; but consensus on the optimal test meal is lacking)
J Neurogastroenterol Motil. 2011 April; 17(2): 189–191
Most reliable T1/2 has been reported after 4h; defined as leased 50% emptying
Euglycamia, avoid medication that delays or accelerates gastric emptying
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2. Wireless capsule motility testing
Capsule that measures pH, temperature, pressure
Change pH (transition from the acid stomach to the alkaline duodenum)
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2. Wireless capsule motility testing
Capsule that measures pH, temperature, pressure
Change pH (transition from the acid stomach to the alkaline duodenum)
3. Breath tests (13C-octonate test)
However, gold standard is gastric emptying scintigraphy
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What can be the cause of gastroparesis?
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What can be the cause of gastroparesis?
• Diabetes mellitus
• Idiopathic gastroparesis
• Hypothyroidism
• Postsurgical gastroparesis (Roux Y Gastrojejunostomie, Fundoplicatio (Nissen)
• Iatrogen gastroparesis
vagus nerve injury (in elder patients ulcus surgery)
Anticholinergic agents, opoids
Glucagon-like peptide-1 analogs (exanatide)
• Cholinergic dysautonomia
( caused by an underlying viral infection CMV, Ebstein-Barr, Varizella)
• Parkinsonism
• Amyloidosis
• Paraneopalstic disease
• Scleroderma
• Mesenteric ischemia
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Principles of the management of gastroparesis?
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Principles of the management of gastroparesis?
• Restoration of fluids (enteral alimentation should be preferred)
• Diet / glycemic control
• Pharmacological therapy
• Surgical intervention
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What are the principles of oral nutrition / diet?
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What are the principles of oral nutrition / diet?
• Meals with low fat content and low –fiber content; 4-5 meals a day
• Supplementation with high calory liquids
• Avoid carbohydrated beverages
• No alcohol and smoking
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Describe medication used for glycemic control and their
effects on gastroparesis?
Substance Gastric emptying
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Describe medication used for glycemic control and their
effects on gastroparesis?
Substance Gastric emptying
GLP-1 analogs (exenatide) delayed
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Describe medication used for glycemic control and their
effects on gastroparesis?
Substance Gastric emptying
GLP-1 analogs (exenatide)
Biguanides (Metformin)
delayed
possible delayed
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Describe medication used for glycemic control and their
effects on gastroparesis?
Substance Gastric emptying
GLP-1 analogs (exenatide)
Biguanides (Metformin)
Alpha Glucosidase inhibitors (acarobose)
delayed
possible delayed
delayed
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Describe medication used for glycemic control and their
effects on gastroparesis?
Substance Gastric emptying
GLP-1 analogs (exenatide)
Biguanides (Metformin)
Alpha Glucosidase inhibitors (acarobose)
dipeptidyl peptidase (DPP) IV inhibitors
(e.g., sitagliptin and vildagliptin)
Sulfonylureas (Glimipirid)
Glitiazones (pioglitazone)
delayed
possible delayed
delayed
no
no
no
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What substances can be used for pharmacological therapy?
Substance Mechanism Side Effect
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What substances can be used for pharmacological therapy?
Metoclopramide
(5 – 40 mg / day)
D2 receptor antagonist Tardive dyskinesia
Extrapyramidal side effects
as acute dystonia, involuntary
movements
Substance Mechanism Side Effect
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What substances can be used for pharmacological therapy?
Metoclopramide
(5 – 40 mg / day)
D2 receptor antagonist Tardive dyskinesia
Extrapyramidal side effects
as acute dystonia, involuntary
movements
Domperidone
(10 – 20 mg / day) D2 receptor antagonist
(lower central side effects)
Elongation of QT interval
cardiac arrhythmia
baseline electrocardiogram
repeate after 6 days
Substance Mechanism Side Effect
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What substances can be used for pharmacological therapy?
Metoclopramide
(5 – 40 mg / day)
D2 receptor antagonist Tardive dyskinesia
Extrapyramidal side effects
as acute dystonia, involuntary
movements
Domperidone
(10 – 20 mg / day) D2 receptor antagonist
(lower central side effects)
Elongation of QT interval
cardiac arrhythmia
baseline electrocardiogram
repeate after 6 days
Erythromycin
(3 mg/kg every 8 h lactobiont QT prolongation
tachyphylaxis by downregulation
of motilin receptors (4 weeks)
Substance Mechanism Side Effect
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What medication can be used as symptomatic therapy?
Substance Mechanism Side Effect
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What medication can be used as symptomatic therapy?
Substance Mechanism Side Effect
Experiences is derived in patients receiving chemotherapy; clinical trials investigating
the effects of anti-emetic substances in patients with gastroparesis is lacking
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What medication can be used as symptomatic therapy?
Phenothiazine
D2, alpha1, 5HT2a, H1 and
M1 receptor antagonists
Substance Mechanism Side Effect
QT prolongation
vein damage
Experiences is derived in patients receiving chemotherapy; clinical trials investigating
the effects of anti-emetic substances in patients with gastroparesis is lacking
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What medication can be used as symptomatic therapy?
Phenothiazine
D2, alpha1, 5HT2a, H1 and
M1 receptor antagonists
Antihistamine agent
Substance Mechanism Side Effect
Promethazine
QT prolongation
vein damage
Sedation, cardiac toxicity
Experiences is derived in patients receiving chemotherapy; clinical trials investigating
the effects of anti-emetic substances in patients with gastroparesis is lacking
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What medication can be used as symptomatic therapy?
Phenothiazine
D2, alpha1, 5HT2a, H1 and
M1 receptor antagonists
Antihistamine agent
5-HT3 receptor
antagonists
Substance Mechanism Side Effect
Promethazine
QT prolongation
vein damage
Sedation, cardiac toxicity
5-HT3 receptor antagonists
QT prolongation
Dizziness, constipation,
headache
Experiences is derived in patients receiving chemotherapy; clinical trials investigating
the effects of anti-emetic substances in patients with gastroparesis is lacking
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What medication can be used as symptomatic therapy?
Phenothiazine
D2, alpha1, 5HT2a, H1 and
M1 receptor antagonists
Antihistamine agent
5-HT3 receptor
antagonists
Substance Mechanism Side Effect
Promethazine
QT prolongation
vein damage
Sedation, cardiac toxicity
5-HT3 receptor antagonists
QT prolongation
Dizziness, constipation,
headache
Neurokinin -1 receptor
antagonist Aprepitant
Dizziness, headache,
elevated liver transaminase
Experiences is derived in patients receiving chemotherapy; clinical trials investigating
the effects of anti-emetic substances in patients with gastroparesis is lacking
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Flow chart summarizing the pharmacological treatment of
gastroparesis
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What surgical treatments can be considered in patients
resistant to pharmacological therapies ?
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What surgical treatments can be considered in patients
resistant to pharmacological therapies ?
- Gastric electrical stimulation
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What surgical treatments can be considered in patients
resistant to pharmacological therapies ?
- Gastric electrical stimulation
- Venting gastrostomy / venting enterostomy
Percutaneous endoscopic gastrostomy leads possibly to the same outcome, but
not yet proven
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What surgical treatments can be considered in patients
resistant to pharmacological therapies ?
- Gastric electrical stimulation
- Surgical pyloroplasty / gastrojejunostomy can be considered; further studies
are required
- Venting gastrostomy / venting enterostomy
Percutaneous endoscopic gastrostomy leads possibly to the same outcome, but
not yet proven
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What surgical treatments can be considered in patients
resistant to pharmacological therapies ?
- Gastric electrical stimulation
- Complete gastrectomy can be considered
- Surgical pyloroplasty / gastrojejunostomy can be considered; further studies
are required
- Venting gastrostomy / venting enterostomy
Percutaneous endoscopic gastrostomy leads possibly to the same outcome, but
not yet proven
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Management of gastroparesis
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Thank you