RECURRENT NAUSEA AND VOMITING: NOT ONLY, BUT ALSO GASTROPARESIS

Transcription

1 RECURRENT NAUSEA AND VOMITING: NOT ONLY, BUT ALSO GASTROPARESIS Thomas L. Abell MD University of Louisville DISCLOSURES NIH GPCRC and NIH DiaComp Grants Medtronic Investigator, ti t Consultant, t Speaker, former Licenser Rhythm Investigator, Consultant Other IP U of MS now: ADEPT-GI UpToDate Reviewer in GI MedStudy GI Section Editor 1

2 TOPICS Overview and Pathophysiology Cyclic Vomiting Syndrome Cannabis Hyperemesis Syndrome Rumination Vestibular Dysfunction Gastroparesis Pathophysiology Based Therapies New Developments and Conclusion OVERVIEW AND PATHOPHYSIOLOGY (PP) Recurrent Nausea and Vomiting (RNAV) Three Possible Causes for RNAV Central Autonomic Enteric May have one alone or any combination Mechanism Important for diagnosis And Crucial for Correct Therapy 2

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4 CYCLIC VOMITING SYNDROME DX Most commonly a Migraine Variant But Personal & Family Hx variable Hx is classic for children and adults: Recurrent attacks of Nausea and Vomiting Often Severe ER and hospital admit May have association ANS signs/sx May be associated with DM Pathophys: Central, ANS and Enteric CYCLIC VOMITING SYNDROME RX Therapy Primary Prevention just as Migraine Beta Blockers, TCA, Other neurol. meds Abortive Therapies try, just like Migraine Tryptans, ergotamines, others in future Full blown attach symptomatic treatment Antiemtics, Anxiolytics, Analagesics IV fluids and correct electrolyte D/Os 4

5 CANNABIS HYPEREMESIS SYNDROME DX Now well described Classically, ll young males using much MJ Pathophys unclear however ANS arousal: hot showers often overused Paradoxical response to MJ Although originally may be self-medication Important to separate if underlying Gp 5

6 CANNABIS HYPEREMESIS SYNDROME RX Abstinence for MJ key Since overuse part of etiology A chemical dependency approach best E.g.: 10% of MJ users may abuse But not all get this syndrome Long term follow up data lacking So other biological aspects may exist RUMINATION DX Technically pseudo-rumination Can be in Children or Adults Can be in Children or Adults Rapid Regurgitation of undigested food Have Classic findings on GDJ manometry Typically Normal Gastric Emptying Described as a Behavioral Disorder Pathophys: Central suspected but unknown 6

7 RUMINATION RX After careful hx & exclusion Gp Behavioral therapy (BT), but Few Centers have specialization Long term success not clear with BT Future work may focus on all 3 Pathophys: Central ANS Enteric 7

8 VESTIBULAR DYSFUNCTION DX Classic Romberg findings in RNAV Advocated as Etiology of Symptoms Close inspection of Chronic N and V (CNAV): Majority if not most patients with ANS D/O Likely true for RNAV Of Interest to NIH GPCRC-studying now Screening or Full ANS testing available Pathophys: Central & Autonomic with?enteric VESTIBULAR DYSFUNCTION RX Can certainly use CNAV & RNAV drugs Dopamine blockers, Scopolamine, Zofran But careful investigation i i of Pathophys. h in order Neurologic evaluation ANS testing Indirect: HRV or Direct: AFT Enteric evaluation: 4 hr solid/liquid GET/ EGG Correlation with Full Thickness Enteric Biopsies 8

9 GASTROPARESIS DX Classically Delayed GET (of solids) But many with RNAV not delayed or rapid Recent ACG Consensus (2013) on Dx: Anatomy Physiology (PP can be Central, ANS, Enteric) Therapy Dissenting views: Non Delay in GET same D/O Recent GPCRC and Full Thickness Bx data 9

10 GASTROPARESIS RX Proper Diagnosis Exploration of All possible Pathophysiologies Therapies: Diet limit to tolerated intake Drugs limited available Devices limits on availability DeNovo new ideas needed Full Thickness Bx Data: Systemic disease? ANALYSIS OF ALL 101 PATIENTS WHO HAD FULL THICKNESS BIOPSY AND EPS 10

11 Thomas L. Abell, MD 11

12 Thomas L. Abell, MD NEW DEVELOPMENTS Full Thickness Biopsy Data Mucosal Neuronal Biopsy Data Liquid gastric emptying test Electrograms: Mucosal low resolution Serosal low resolution Serosal high resolution Serologic and Genetic Testing 12

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14 Thomas L. Abell, MD PILOT STUDIES IN MNF DENSITY IMAGING (CONFOCAL MICROSCOPY) DM GP REDUCTIONS RESULTS-I PERCENTAGE ABNORMAL DETECTED (Antibodies/Serum parameters) Plasma Amino Acid 36% 14

15 EXAMPLE OF AN ANTRAL EGG TRACING OF A PATIENT WITH FAR OF (7CPM/0.1MV) = 70 Amplitude 0.1mv 7 cpm Frequency (cpm) PCB Electrodes Ann Biomed Eng 2009;37:

16 ABNORMAL VELOCITIES Activation Map Electrograms CONDUCTION BLOCK Activation Map Electrograms 16

17 ECTOPIC PACEMAKING ( cpm) CONCLUSION Recurrent Nausea and Vomiting Many causes with similar presentations Pathophysiology (PP): Concepts and Application PP Helpful for Diagnosis & Crucial for Therapy New Techniques: Better Understanding of PP New Therapies: Emerging, some endoscopic www. Gpcrc.us and other sites 17