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Gastroparesis: Inpatient
Management
Canadian Society of Hospital Medicine
IL Epstein, MD, FRCPC
Assistant Professor
Department of Medicine, Dalhousie University
Friday Sept 29, 2017
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Disclosures
2017 Ad Board Attendee:
Takeda
Abbvie
No conflicts with any products discussed in
this presentation
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Objectives
1. Describe the presentation & symptoms of
gastroparesis in hospitalized patients
2. Demonstrate an approach to diagnosis of
gastroparesis
3. Appraise therapeutic options for
management of complex inpatient
gastroparesis
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Case
55 yr old female
PMH Chronic back pain, DM, HTN
Meds: Glyburide, ASA, Ramipril, Metoprolol,
ASA, Hydromorphone
Admitted with UTI, severe nausea
Since admission refractory nausea, frequent
vomiting, abdominal pain
Refractory to anti-emetics; labile sugars;
unable to discharge
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Symptoms
Nausea (93%)
Vomiting (68-84%)
Abdominal pain (46-90%)
*rarely the only / predominant symptom
Early satiety (60-86%)
Postprandial fullness, bloating, weight loss
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Differential Diagnosis
Functional dyspepsia
Mechanical obstruction
Rumination
CVS
Cannabinoid hyperemesis syndrome
Eating disorder
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Pathophsyiology
Often Multifactorial
Gastric “neuropathy”; rarely myopathy
Sensory & motor dysfunction
Vagal injury may be cause, but rare, and not a
factor in all cases
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Pathophysiology
https://www.slideshare.net/kaj4/gut-motility-lecture
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https://www.slideshare.net/suadboulevardez/chapter-17-gitmod
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https://www.slideshare.net/wenyelin/gut-hormone-and-its-implication-in-glucose-homeostasis-11661727
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Gastric Emptying
http://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/emptying.html
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Causes
3 main categories
Idiopathic (includes neurologic disease,
autoimmune)
Diabetic (symptoms worse in type 1)
Post-surgical
Others (*inpatients, often reversible):
Hyperglycemia (>12mM/L)
Post-viral (*CMV, EBV, VZV)
Medications
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Medications
TCAs
Alpha-2-agonists (clonidine), CCBs
Dopamine agonists, muscarinic cholinergic
receptor antagonists
Octreotide
Phenothiazines
Cyclosporine
GLP1 Analogs (Liraglutide)
Opioids!
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Medications: Opioids
Curr Treat Options Gastro (2016) 14:478–494
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Medications: Opioids
Stomach & colon have highest numbers of mu
receptors1
Constipation most common GI adverse event, but
nausea, vomiting, bloating, GERD also common
Occurs with mixed agonists/antagonists as well
(ex. buprenorphine used in opiate detox)2
1. Curr Treat Options Gastro (2016) 14:478–494 2. Addiction. 2007 Mar;102(3):490-1
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60-year-old on long-term morphine for chronic back pain, presenting with acute
abdominal painThe American Journal of the Medical Sciences Volume 350, Number 3, September 2015
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Diagnosis
To establish a diagnosis patient must have
1. Symptoms
2. Gastric outlet obstruction ruled out
3. Documented delayed gastric emptying
Clinical guideline: management of gastroparesis.
Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.
Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.
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Diagnosis: Key Tests
Gastric emptying study
4 hr solid phase gastric emptying
UGI series/Gastroscopy
Exclude mechanical obstruction (e.g. small bowel
mass, SMA syndrome)
Retained food after overnight fast suggestive
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Other diagnostic tests
Capsule
Gastric motility study
Breath test
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Gastric emptying study
Scintigraphic gastric emptying of solids
ie Tc sulfur colloid labeled egg salad sandwich
Most reliable parameter is gastric retention of
solids at 4 hours
Completed off medications that affect gastric
emptying > 48 hrs before testing
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Gastric images obtained during simultaneous assessment of gastric emptying and accommodation. Hrair
P. Simonian et al. J Nucl Med 2004;45:1155-1160
(c) Copyright 2014 SNMMI; all rights reserved
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Lab tests
CBC
Fasting glucose; A1c
Albumin
TSH
Consider AI workup+/- viral or paraneoplastic
workup
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Management Principles
Modify what you can:
Tight glycemic control
Remove potential meds
Diet
Prokinetics
Symptom control: Anti-emetics
Tubes: Nutrition +/- Venting
Compassionate: Electrical stimulation
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Management: Diet/lifestyle
Avoid:
fat (slows gastric emptying)
nondigestible (insoluble) fibre – requires effective
interdigestive antral motility
carbonated beverages (increase distension)
EtOH & smoking (decrease antral contractility)
Small, frequent meals (4-5/day)
Liquid meals if intolerant of solids
emptying of liquids is often normal
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Management: Prokinetics
Metoclopramide
dopamine-2 receptor antag, 5-HT4 ag, weak 5-
HT3 receptor antag
↑ gastric antral contractions, ↓ postprandial fundus
relaxation
SEs: anxiety, restlessness, depression, ↑PRL, ↑QT
interval, dystonia (0.2%), tardive dyskinesia (1%)
Domperidone
dopamine 2 antagonist
SEs: ↑PRL, check QT interval
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Management: Prokinetics
Erythromycin: 3rd line
Motilin agonist; causes high amplitude propulsive
gastric contractions
Can be used 3rd line after domperidone or
metoclopramide
Liquid TID 40 – 250 mg ac meals
Works best IV
≤4 weeks at a time: tachyphylaxis
SEs: ↑QT, abdo pain, ototoxicity, sudden death
No trials for azithromycin but might be as good
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Management: Prokinetics
Cisapride
5HT4 Agonist
10-20 mg QID ac meals
Stimulates antral and duodenal motility which is
maintained long term
Major drug interactions: macrolides, antifungals,
phenothiazine
Resulted in cardiac arrhythmia and death: QT
interval
Special access Health Canada only; need to
monitor QT; ensure <450 msec
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Management: Prokinetics
Prucalopride
5HT4 agonist
dose of 1 to 4 mg OD
safe and well tolerated
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Management: Prucalopride
RCT: 34 pts with gastroparesis, 6 with DM
prucalopride 2 mg OD vs. placebo
4 weeks of therapy; 2-week washout, then
crossover
Gastric half-emptying time:
Signficant decrease in prucalopride group: 87.9
minutes vs. 118, P < .05
Also reduced scores for nausea/vomiting,
fullness/satiety, bloating/distension, and QOL
1 episode of intestinal volvulus, 1 diarrhea
resulting in discontinuationhttp://www.firstwordpharma.com/node/1327032#axzz4thfvA4RM
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Management: Antiemetics
Antihistamines: e.g. Diphenhydramine
12.5 mg orally / IV q6-8h
5HT3 antagonists
ondansetron 4 - 8 mg TID
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Management: refractory
symptoms
percutaneous endoscopic gastrostomy tube
decompress upper GI tract
Reduces need for hospitalization for acute
exacerbations of dysmotility
percutaneous endoscopic jejunostomy tube
enteral nutrition
unintentional weight loss 10% of more / 3-6 mos,
or repeated hospitalizations
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Tube Selection
Tube Use Limitations
NG Gastric decompression
in acute mgmnt
Not long term;
uncomfortable; gastric
feeding
NE Trial feeding to see if
small bowel feeding
tolerable
Not long term; Migration
of tube particularly with
vomiting
PEG Venting, decompression,
drainage
Gastric feeding
PEG-J Venting and small bowel
feeding
Migration of tube; pyloric
obstruction
J Small bowel feeding No G venting
PEG and J Two sites – one for
venting and nutrition
Increased risk leaking,
infection
Clinical guideline: management of gastroparesis.
Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.
Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.
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Management: Gastric electrical
stimulation
high-frequency gastric electrical stimulation
(12/minute)
compassionate treatment for refractory nausea &
vomiting
Systematic review: improves symptom severity &
gastric emptying a subset of pts (diabetic)
Gastric pacing: regular slow-wave rhythm
Impractical - external current source too large
Lal et al. Gastric electrical stimulation with the Enterra system: a systematic review. Gastroenterology research and practice 2015;1.
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Take Home Points
1. Gastroparesis can cause severe
symptoms; suspect in diabetics, post op and
with opioids
2. Diagnostic work up includes gastroscopy,
UGI series, gastric emptying study
3. Modify what you can – glycemic control,
meds, diet
4. Prokinetics, diet and time are mainstays of
therapy
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Questions