Diabetic Gastroparesis

Ali DjumhanaDiv. Gastroenterology dan Hepatologi

Bagian Ilmu Penyakit Dalam RS Hasan Sadikin – FK Unpad

Bandung

Gastroparesis

Gastroparesis is a form of gastric paralysis ;chronic symptoms may result from abnormal gastric motility associated with delayed gastric emptying in the absence of mechanical outlet obstruction.

The symptoms that suggest gastroparesis are variable include nausea, vomiting, abdominal bloating, early satiety , and abdominal pain or discomfort

The symptoms may mimic structural disorders (PUD,intestinalobstruction,pancreatobliary disorders) and there also overlap between symptoms of gastroparesis and FD

Relationship of symptoms to gastric motor function is poor Parkman HP ( 2004); Park MI(2006)

Etiology of Gastroparesis

28%

8%

29%

14%

10%

4%4% 3%

Idiopathic

Postviral

Diabetic

Postsurgical

Parkinsons

Pseudoobstruction

Scleroderma

Miscellaneous

Soykan I et al. (1998)

Epidemiology Female > Male (~ 4:1) Delayed gastric emptying were found

:– 20 - 40 % of pts with F D– 26 - 68% % of pts with Diabetes

Incidence of delayed gastric emptying:– 4.5% DM 1– 1% DM 2– 0.1%Non DM

Physiology of Gastric motility

=Parasympatetic ( N Vagus)=Sympatetic=Enteric neural system=Neurotransmitter (Acetylcholine,dopamin,serotonin)=Hormone ( glucose regulating

hormone)=Food composition (fat,CHO,solid,fluid)

Regulation of gastric motility

Physiology of gastric motilityMotor function of stomach is controlled at three main levels Autonomic nervous system Enteric neuronal system Interstitial Cell of Cajal Smooth muscle cell

Several subsystems are involved: afferent receptors neurohumoral substances circulating hormones

ICCsICCs

Motility of the gut

excitation

inhibition

Physiology of gastric emptying

Gastric emptying results of : Tonic contraction of the fundus, Phasic contraction of the antrum, Inhibitory forces of pyloric and

duodenal contraction

Pathophysiology Diabetic gastropsresis

Gut 2010;59:1716-1726

Pathophysiology Diabetic gastroparesis

Pathophysiology of Gastroparesis

Abnormal gastric motility Abnormal gastric accommodation Gastric dysrhythmias Antral hypomotility

Evaluation of patients suspected gastroparesis

Gastroparesis is diagnosed by demonstrating delayed gastric emptying in a symptomatic individual after exclusion of other etiologies of symptoms

Gastroparesis is often suspected in patient subgroup with specific profile DM After vagotomy FD GERD

Parkman HP ( 2004); Rayner CK (2005)Park MI(2006)

Evaluation of patients suspected gastroparesis

HT and PELaboratory testingEvaluation for organic disordersEvaluation for delayed gastric emptyingEvaluation of response to treatment trialFurther evaluation

History taking and Physical Examination

HT Differentiated of vomiting from regurgitation and ruminating Risk factors

Poor glycaemic controlled Female

History of medication (GLP-1 agonist/receptor analogue,etc) PE

Hydration status Nutrition status Succussion splash

Diagnosis

Gut 2010;59:1716-1726

Evaluation of patients Suspected Gastroparesis

Test to assess gastric motor and myoelectrical function

Assessing gastric emptying Upper Ba radiography study Scintigraphy USG MRI Breath test

Assessing gastric contractility Antroduodenal manometri Gastric barostat Satiety test

Assessing electrical activity EGG

Treatment of symptomatic gastroparesis

Nutrition teraphy– Hydration and corection of electrolite imbalance– Liquid or parenteral nutrition– Micronutrient– Vitamins ( Cobalamin,vitamin C, etc)

To tighten glicaemic control Prokinetic agents Anti emetic agents Others modality

– Botulinum injection– Gastric electrical stimulation– Gastrostomy and jejunostomy placement– Surgical treatment

Treatment of symptomatic gastroparesis

Dietary modification– Liquid diet is recommended to patient with

gastroparesis who have delayed solid emptying

– Frequent (4 – 5 x daily) and small size diet– Minimized fat and fiber intake– Avoid alcohol and carbonated beverages

To tighten glicaemic control.

Treatment of symptomatic gastroparesis

Medical treatment Prokinetic agent

– Dopaminergic agent Dopaminergic antagonist

– Metoclopramide– Domperidone– Mosapride

– Serotonergic agent 5HT4 agonist

– Pucalopride– Cisapride– Tegaserod

5HT3 antagonist– Ondansetron,granisetron

– Motilin agonist Eritromycin

Antiemetic agent– Phenotiazine

Psychotropic – Benzodiazepin– Antidepresant

New and other agents Motilides

– Mitemcinal– ABT 229

CCK antagonist– Loxiglumide

NO donors– Sidenafil ?

Ghrelin 5 HT1 agonist

– Sumatriptan– Buspiron

Treatment of symptomatic

gastroparesis

 Commonly used prokinetic drugs

Rayner CK and Horowitz M (2005) New management approaches for gastroparesisNat Clin Pract Gastroenterol Hepatol 2: 454–462 doi:10.1038/ncpgasthep0283

Treatment of symptomatic gastroparesis

Others therapeutic modalities Endoscopic treatment

– Botulinum toxin injection Gastric electric stimulation Gastrostomy and jejunostomy placement Ginger, Acupuncture Surgical treatment

Improvement

Presumptive diagnosis of gastroparesis

Assessment of patients to rule out mechanical obstruction or another diseases

Nutrition;glycaemic controlEmpiric trial of prokinetic for 4-8 wks

History of symptoms gastroparesis

No improvement

Treatment continueAnd Pulse Tx

Perform UG-Endos/ Ba meal

Negative finding Structural lesion

Appropriate Tx High dose medical Tx

Test Gastric emptying

Improvement No ImprovementAbnormal Normal

High dose prokineticOr other modalities Re-evaluate the D/

Improvement

Conclusion (1)

Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction

Diabetic gastroparesis is the main cause of gastroparesis

Scintigraphy is a gold-standard for diagnosis

Conclusion (2)Patients with presumptive diagnosis

gastroparesis should be cared for empirical / trial treatment.

The treatment include ;Nutrition teraphy (Macro and micro nutrient,vitamins etc), metabolic control and prokinetic agent

Novel treatment including new prokinetics, botulinum toxin injection,gastric electrical stimulation have been tested in patients with gastroparesis