Dr. Patsy Smyth, FNP-BC

Transcription

1 Dr. Patsy Smyth, FNP-BC

2 Gastroparesis literally translated means stomach paralysis. Gastroparesis is a syndrome characterized by delayed gastric emptying in absence of mechanical obstruction of the stomach. The cardinal symptoms include postprandial fullness (early satiety), nausea, vomiting, and bloating.

3 Diabetes accounts for almost one third of cases of gastroparesis Although gastroparesis appears to be more common in type 1 diabetes compared with type 2, the increased prevalence of type 2 diabetes has resulted in larger numbers of patients with gastroparesis associated with type 2 diabetes

4 Gastroparesis was associated with higher mortality and morbidity, and delayed radionuclide gastric emptying studies predict morbidity, increased hospitalizations, emergency department, and doctor visits in diabetics with symptoms of gastroparesis.

5 Thos with gastroparesis are more likely to have cardiovascular disease, hypertension, and retinopathy, suggesting that the underlying complication might be related to microangiopathies or macroangiopathies, which are known complications of poor diabetic control.

6 Several abnormalities in diabetes might result in gastric motor dysfunction, including autonomic neuropathy, enteric neuropathy involving excitatory and inhibitory nerves, abnormalities of ICC, acute fluctuations in blood glucose, incretin-based medications used to normalize postprandial blood glucose, and psychosomatic factors

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8 Gastric emptying involves integration of fundic tone and antral phasic contractions with inhibition of pyloric and duodenal contractility. Gastric emptying requires interactions between smooth muscle, enteric and extrinsic autonomic nerves, and specialized pacemaker cells, the interstitial cells of Cajal (ICC)

9 Autonomic neuropathy is commonly encountered in diabetic gastroparesis Vagus nerve dysfunction is also thought to mediate some of the acute effects of hyperglycemia because a similar effect can be induced by subdiaphragmatic vagotomy Morphologic studies of the vagus nerve have revealed demyelination

10 Upper Endoscopy Gastric Emptying Study is a widely available nuclear medicine test that examines the rate of emptying of solid or liquid material from the stomach Gastroduodenal manometry is a test that measures how well the smooth muscle of the stomach and small intestine contracts and relaxes

11 A Small Intestinal X-ray is a contrast radiograph used to outline the anatomy of the small bowel. Wireless capsule GI monitoring system (SmartPill ) Note: not to be used with patients who have had previous GI surgery

12 Gastroparesis is diagnosed by demonstrating delayed gastric emptying in a symptomatic patient after exclusion of other potential etiologies of symptoms and obstruction with endoscopy or radiologic imaging The current diagnostic method of choice is scintigraphic measurement of the emptying of solids for those who cannot use the Smartpill

13 In the absence of obstruction, retained food in the stomach after an overnight fast is suggestive of ineffective antral interdigestive motility and gastroparesis

14 Metoclopramide, 10-mg tablet 4 times a day provides evidence of reduced nausea, vomiting, fullness, early satiety and improved meal tolerance, of significantly reduced nausea and post-meal fullness, and of significantly improved gastric emptying relative to baseline Domperidone is another medication, similar to metoclopramide, that acts on dopamine receptors. Domperidone does not have the side effect of tardive dyskenisia and agitation that are seen with metoclopramide because it does not act on receptors in the brain. However it is only available on a limited basis in the US

15 An FDA black box warning informed practitioners about the adverse effects of metoclopramide, especially tardive dyskinesia, an irreversible neurologic complication that might affect orofacial, lingual, and axial muscles and might interfere with nutrition, manual dexterity, and ambulation. Development of this condition is directly related to the duration of metoclopramide use and the number of doses taken. Older patients, especially women, are at greatest risk. The FDA recommended that treatment with metoclopramide should not exceed 3 months.

16 The national prescription databases suggest the risk of metoclopramide-induced tardive dyskinesia is likely far less than 1% which is much lower than the estimated 1% 10% risk previously suggested in national guidelines Tardive dyskinesia might represent an idiosyncratic response, conceivably related to genetic susceptibility

17 Erythromycin is a commonly used antibiotic that binds to receptors in the small intestine and stomach called motilin receptors. Stimulation of motilin receptors results in contraction and improved emptying of the stomach. The beneficial effect of erythromycin can be short lived as individuals who use it frequently have a high likelihood of developing tolerance to the medication. Perhaps the best use of erythromycin is for a worsening of symptoms or used on an intermittent basis to reduce the potential for tolerance.

18 Cisapride (Propulsid) binds to serotonin receptors located in the wall of the stomach that leads to contraction of stomach smooth muscle and improved gastric emptying. In the late 1990 s cisapride was taken off the market due to complications of cardiac arrhythmias in patients who were using this drug. It is once again available but its use is restricted. Individuals with underlying kidney or heart disease should not use cisapride.

19 Octreotide, a medication sometimes used to treat diarrhea has been shown in one small study to speed up gastric emptying in patients with scleroderma. In a separate study involving normal volunteers, octreotide caused a decrease in the uncomfortable sensation of fullness after a meal. This suggests that octreotide may prove to be beneficial in persons with gastroparesis, but more studies are needed before it could be recommended as a safe and effective treatment. It is given IM thus may not be useful in primary care

20 Surgery for gastroparesis is reserved for individuals with severe and refractory symptoms, intolerance to therapy, or malnutrition related to the condition. Venting tubes placed into the stomach may reduce symptoms and hospitalizations for individuals with recurrent vomiting and dehydration. Varieties of tubes, including button gastrostomy tubes and percutaneous gastrostomy tubes are available to vent trapped air from within the poorly contracting stomach.

21 An area generating a great deal of interest and research is the use of electrical stimulation to enhance gastrointestinal contractile activity. This technique uses electrodes that are surgically or endoscopically attached to the stomach wall and when stimulated, trigger stomach contractions Patients have a better quality of life and spend less time in the hospital for gastroparesis symptoms after the placement of the electrical stimulator.

22 The management of pain remains a challenge, which has not been addressed in clinical trials of patients with gastroparesis. Tricyclic antidepressants, which are somewhat effective for abdominal pain in functional bowel disorders, are often used as first-line therapy for pain in gastroparesis. Second-line approaches for pain in gastroparesis are the weak μ-opioid receptor agonist, tramadol (which also releases serotonin and inhibits the reuptake of norepinephrine), and the γ-aminobutyric acid analog, gabapentin.

23 The potential of inducible pluripotent stem (ips) cells derived from somatic cells represents a novel renewable source of tissue precursors. The potential of ips cells is considered to be equivalent to that of human embryonic stem cells, facilitating the treatment or cure of diabetes mellitus and its neurodegenerative complications with the potential of evading the adaptive immune response that otherwise limits allogeneic cell based therapies. It remains to be determined whether the intricate extrinsic and enteric neural apparatus and the ICC can be reconstituted to restore normal gastric function and reverse gastroparesis.

24 Low fat diet Avoidance of consuming fluids during and 30 minutes after meals Fiber when eaten should be chewed well and cooked until soft. Food that is poorly digested can collect in the stomach and form what is called a bezoar This mass of undigested matter may cause a blockage, preventing the stomach from emptying and result in nausea and pain

25 Among alternative medicine therapies, acupuncture is the method most studied in treatment of nausea and vomiting; one study reported impressive relief in 94% of patients