Management of Gastroparesis
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1 Management of Gastroparesis Bible Class Jan Hendrik Niess As published in Am J Gastroenterol Jan;108(1):18-37
2 What is the definition of gastroparesis? What are cardinal symptoms of gastroparesis?
3 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?
4 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
5 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
6 How can be tested for delayed gastric emptying?
7 How can be tested for delayed gastric emptying? Euglycamia, avoid medication that delays or accelerates gastric emptying
8 How can be tested for delayed gastric emptying? Euglycamia, avoid medication that delays or accelerates 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 April; 17(2): Most reliable T1/2 has been reported after 4h; defined as leased 50% emptying
9
10 2. Wireless capsule motility testing Capsule that measures ph, temperature, pressure Change ph (transition from the acid stomach to the alkaline duodenum)
11 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
12 What can be the cause of gastroparesis?
13 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
14 Principles of the management of gastroparesis?
15 Principles of the management of gastroparesis? Restoration of fluids (enteral alimentation should be preferred) Diet / glycemic control Pharmacological therapy Surgical intervention
16 What are the principles of oral nutrition / diet?
17 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
18 Describe medication used for glycemic control and their effects on gastroparesis? Substance Gastric emptying
19 Describe medication used for glycemic control and their effects on gastroparesis? Substance GLP-1 analogs (exenatide) Gastric emptying delayed
20 Describe medication used for glycemic control and their effects on gastroparesis? Substance GLP-1 analogs (exenatide) Biguanides (Metformin) Gastric emptying delayed possible delayed
21 Describe medication used for glycemic control and their effects on gastroparesis? Substance GLP-1 analogs (exenatide) Biguanides (Metformin) Alpha Glucosidase inhibitors (acarobose) Gastric emptying delayed possible delayed delayed
22 Describe medication used for glycemic control and their effects on gastroparesis? Substance GLP-1 analogs (exenatide) Biguanides (Metformin) Alpha Glucosidase inhibitors (acarobose) Gastric emptying delayed possible delayed delayed dipeptidyl peptidase (DPP) IV inhibitors (e.g., sitagliptin and vildagliptin) Sulfonylureas (Glimipirid) Glitiazones (pioglitazone) no no no
23 What substances can be used for pharmacological therapy? Substance Mechanism Side Effect
24 What substances can be used for pharmacological therapy? Substance Mechanism Side Effect Metoclopramide (5 40 mg / day) D2 receptor antagonist Tardive dyskinesia Extrapyramidal side effects as acute dystonia, involuntary movements
25 What substances can be used for pharmacological therapy? Substance Mechanism Side Effect Metoclopramide (5 40 mg / day) Domperidone (10 20 mg / day) D2 receptor antagonist D2 receptor antagonist (lower central side effects) Tardive dyskinesia Extrapyramidal side effects as acute dystonia, involuntary movements Elongation of QT interval cardiac arrhythmia baseline electrocardiogram repeate after 6 days
26 What substances can be used for pharmacological therapy? Substance Mechanism Side Effect Metoclopramide (5 40 mg / day) Domperidone (10 20 mg / day) D2 receptor antagonist D2 receptor antagonist (lower central side effects) Tardive dyskinesia Extrapyramidal side effects as acute dystonia, involuntary movements 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)
27 What medication can be used as symptomatic therapy? Substance Mechanism Side Effect
28 What medication can be used as symptomatic therapy? Experiences is derived in patients receiving chemotherapy; clinical trials investigating the effects of anti-emetic substances in patients with gastroparesis is lacking Substance Mechanism Side Effect
29 What medication can be used as symptomatic therapy? Experiences is derived in patients receiving chemotherapy; clinical trials investigating the effects of anti-emetic substances in patients with gastroparesis is lacking Substance Mechanism Side Effect Phenothiazine D2, alpha1, 5HT2a, H1 and M1 receptor antagonists QT prolongation vein damage
30 What medication can be used as symptomatic therapy? Experiences is derived in patients receiving chemotherapy; clinical trials investigating the effects of anti-emetic substances in patients with gastroparesis is lacking Substance Mechanism Side Effect Phenothiazine D2, alpha1, 5HT2a, H1 and M1 receptor antagonists QT prolongation vein damage Promethazine Antihistamine agent Sedation, cardiac toxicity
31 What medication can be used as symptomatic therapy? Experiences is derived in patients receiving chemotherapy; clinical trials investigating the effects of anti-emetic substances in patients with gastroparesis is lacking Substance Mechanism Side Effect Phenothiazine D2, alpha1, 5HT2a, H1 and M1 receptor antagonists QT prolongation vein damage Promethazine Antihistamine agent Sedation, cardiac toxicity 5-HT3 receptor antagonists 5-HT3 receptor antagonists QT prolongation Dizziness, constipation, headache
32 What medication can be used as symptomatic therapy? Experiences is derived in patients receiving chemotherapy; clinical trials investigating the effects of anti-emetic substances in patients with gastroparesis is lacking Substance Mechanism Side Effect Phenothiazine D2, alpha1, 5HT2a, H1 and M1 receptor antagonists QT prolongation vein damage Promethazine Antihistamine agent Sedation, cardiac toxicity 5-HT3 receptor antagonists Aprepitant 5-HT3 receptor antagonists Neurokinin -1 receptor antagonist QT prolongation Dizziness, constipation, headache Dizziness, headache, elevated liver transaminase
33 Flow chart summarizing the pharmacological treatment of gastroparesis
34 What surgical treatments can be considered in patients resistant to pharmacological therapies?
35 What surgical treatments can be considered in patients resistant to pharmacological therapies? - Gastric electrical stimulation
36 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
37 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 - Surgical pyloroplasty / gastrojejunostomy can be considered; further studies are required
38 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 - Surgical pyloroplasty / gastrojejunostomy can be considered; further studies are required - Complete gastrectomy can be considered
39 Management of gastroparesis
40 Thank you
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