Gastroparesis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]
Overview
The medical management of gastroparesis consists of dietary modification, hydration and nutritio, optimization of glycemic contro and pharmacotherapy.
Medical Therapy
The medical therapy of gastroparesis is as follows:
Initial management
The first line management of gastroparesis consists of the following steps:[1][2][3][4]
- Dietary modification
- Hydration and nutrition
- Optimize glycemic control
- Pharmacotherapy
Dietary modification
Patients with gastroparesis should be advised the following dietary regimen.[5][6][7]
| Dietary modification in gastroparesis |
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Hydration and nutrition
- Vitamin supplementation and adequate hydration play an important role in the medical managemnent of gastroparesis to prevent electrolyte imbalance, acidosis and, dehydration.[10]
- Patients with mild gastroparesis can be fed orally.
- Homogenized meals should be given to patients who are unable to tolerate solids.
Optimize glycemic control
- Delayed gastric emptying is most commonly seen in diabetics.[11][12][13]
- High glycemic levels are associated with delayed gastric emptying and eventually leads to gastroparesis.
- Therefore, its important to maintain the glucose levels in these patients.
The following drugs should be avoided in diabetics as they delay gastric emptying:
- Incretin-based drugs such as Pramilintide
- GLP-1 analoges such as Exanatide
Pharmacotherapy
Prokinetics
Anti-emetics
Antibiotics
Gastric electrical stimulation
It is the preferred modality of treatment in the following patients:[14][15]
- Patients with symptoms refractory to medical therapy for at least one year.
- It is beneficial for diabetics as it improves symptom serverity.
Video
The following video demonstrates the procdure of gastric electrical stimulation. {{#ev:youtube|-S_JKjtQXUc}}
Medication
Several medications are used to treat gastroparesis. Your doctor may try different medications or combinations to find the most effective treatment. Discussing the risk of side effects of any medication with your doctor is important.
- Metoclopramide (Reglan): This drug stimulates stomach muscle contractions to help emptying. Metoclopramide also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug include fatigue, sleepiness, depression, anxiety, and problems with physical movement.
- Erythromycin: This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects include nausea, vomiting, and abdominal cramps.
- Domperidone: This drug works like metoclopramide to improve stomach emptying and decrease nausea and vomiting. The FDA is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. Use of the drug is restricted in the United States.
- Other medications: Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar in the stomach, the doctor may use an endoscope to inject medication into it to dissolve it.
- Viagra: Viagra which increases blood flow to the genital area, is also being used by some practitioners to stimulate the GI tract in diabetic gastroparesis.
- Antidepressant: Mirtazapine has also proven effective in the treatment of gastroparesis unresponsive to conventional treatment. This is due to its anti-emetic and appetite stimulant properties. Mirtazapine acts on the same serotonin receptor as the popular anti-emetic Ondansetron[16].
Dietary Changes
Changing your eating habits can help control gastroparesis. Your doctor or dietitian may prescribe six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. In more severe cases, a liquid or pureed diet may be prescribed.
The doctor may recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion—a problem you do not need if you have gastroparesis—and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.
Feeding Tube
If a liquid or pureed diet does not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy, is inserted through the skin on your abdomen into the small intestine. The feeding tube bypasses the stomach and places nutrients and medication directly into the small intestine. These products are then digested and delivered to your bloodstream quickly. You will receive special liquid food to use with the tube. The jejunostomy is used only when gastroparesis is severe or the tube is necessary to stabilize blood glucose levels in people with diabetes.
Parenteral Nutrition
Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.
This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult period with gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.
Gastric Electrical Stimulation
A gastric neurostimulator is a surgically implanted battery-operated device that releases mild electrical pulses to help control nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications. Further studies will help determine who will benefit most from this procedure, which is available in a few centers across the United States.
Botulinum Toxin
The use of botulinum toxin has been associated with improvement in symptoms of gastroparesis in some patients; however, further research on this form of therapy is needed.
References
- ↑ Wytiaz V, Homko C, Duffy F, Schey R, Parkman HP (2015). "Foods provoking and alleviating symptoms in gastroparesis: patient experiences". Dig Dis Sci. 60 (4): 1052–8. doi:10.1007/s10620-015-3651-7. PMID 25840923.
- ↑ Homko CJ, Duffy F, Friedenberg FK, Boden G, Parkman HP (2015). "Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis". Neurogastroenterol Motil. 27 (4): 501–8. doi:10.1111/nmo.12519. PMID 25600163.
- ↑ Ferdinandis TG, Dissanayake AS, De Silva HJ (2002). "Effects of carbohydrate meals of varying consistency on gastric myoelectrical activity". Singapore Med J. 43 (11): 579–82. PMID 12680528.
- ↑ Ramzan Z, Duffy F, Gomez J, Fisher RS, Parkman HP (2011). "Continuous glucose monitoring in gastroparesis". Dig Dis Sci. 56 (9): 2646–55. doi:10.1007/s10620-011-1810-z. PMID 21735078.
- ↑ Bujanda L (2000). "The effects of alcohol consumption upon the gastrointestinal tract". Am J Gastroenterol. 95 (12): 3374–82. doi:10.1111/j.1572-0241.2000.03347.x. PMID 11151864.
- ↑ Stermer E (2002). "Alcohol consumption and the gastrointestinal tract". Isr Med Assoc J. 4 (3): 200–2. PMID 11908263.
- ↑ Miller G, Palmer KR, Smith B, Ferrington C, Merrick MV (1989). "Smoking delays gastric emptying of solids". Gut. 30 (1): 50–3. PMC 1378230. PMID 2920927.
- ↑ Ogorek CP, Davidson L, Fisher RS, Krevsky B (1991). "Idiopathic gastroparesis is associated with a multiplicity of severe dietary deficiencies". Am J Gastroenterol. 86 (4): 423–8. PMID 2012043.
- ↑ Camilleri M (1994). "Appraisal of medium- and long-term treatment of gastroparesis and chronic intestinal dysmotility". Am J Gastroenterol. 89 (10): 1769–74. PMID 7942664.
- ↑ Parkman HP, Yates KP, Hasler WL, Nguyan L, Pasricha PJ, Snape WJ; et al. (2011). "Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis". Gastroenterology. 141 (2): 486–98, 498.e1–7. doi:10.1053/j.gastro.2011.04.045. PMC 3499101. PMID 21684286.
- ↑ Camilleri M (2007). "Clinical practice. Diabetic gastroparesis". N Engl J Med. 356 (8): 820–9. doi:10.1056/NEJMcp062614. PMID 17314341.
- ↑ Koch KL, Calles-Escandón J (2015). "Diabetic gastroparesis". Gastroenterol Clin North Am. 44 (1): 39–57. doi:10.1016/j.gtc.2014.11.005. PMID 25667022.
- ↑ Holzäpfel A, Festa A, Stacher-Janotta G, Bergmann H, Shnawa N, Brannath W; et al. (1999). "Gastric emptying in Type II (non-insulin-dependent) diabetes mellitus before and after therapy readjustment: no influence of actual blood glucose concentration". Diabetologia. 42 (12): 1410–2. doi:10.1007/s001250051311. PMID 10651258.
- ↑ Guerci B, Bourgeois C, Bresler L, Scherrer ML, Böhme P (2012). "Gastric electrical stimulation for the treatment of diabetic gastroparesis". Diabetes Metab. 38 (5): 393–402. doi:10.1016/j.diabet.2012.05.001. PMID 22742875.
- ↑ Health Quality Ontario (2006). "Gastric electrical stimulation: an evidence-based analysis". Ont Health Technol Assess Ser. 6 (16): 1–79. PMC 3413096. PMID 23074486.
- ↑ Mirtazapine for Severe Gastroparesis Unresponsive to Conventional Prokinetic Treatment