History

• 4th Post op day• Nausea +• Vomiting:3episodes• Abdomen distended• Not passed flatus or motion

Post Surgical Gastroparesis

Presenter-Dr.Amit Goswami

Introduction

• Post prandial nausea and vomiting and

gastric atony without mechanical

obstruction

• Pathogenesis not well explained

• Definition varies

Gastric pacesetter potentials or slow wavesCutaneous 3cmp EGG

waves

Fundus

Corpus

Duodenum

Antrum

Peristaltic

wave

3 cpm slow waves plusaction potentials

Etiology of Gastroparesis

Clinical Manifestations

• Nausea 92%• Vomiting 84%• Bloating 75%• Early Satiety 60%

Gastroparesis Cardinal Symptom Index (GCSI)

• Each parameter scored on 0-5 scale1. Nausea

2. Retching

3. Vomiting

4. Stomach Fullness

5. Not able to finish normal-sized meal

6. Feeling excessively full after meals

7. Loss of appetite

8. Bloating (feeling like you need to loosen your clothes)

9.Stomach or belly visibly larger

Grade

Post Surgical Gastroparesis

Incidence

• Peptic ulcer surgery with vagotomy

• Gastrectomy(0.4%-5%)

• Pancreatoduodenectomy(20-50%)

• Pancreatic cancer cryoablation(50-70%)

• Heart and lung transplantation

ISGPS suggested definition

• Absence of mechanical gastric outlet obstruction

• Gastric juice aspirate >800ml for more than 10

days

• No abnormalities in water, salt, electrolytes, or

acid–alkali balance

• Absence of underlying diseases

• No history of using suggestive agents

Pathogenesis-Surgical factors

• Multifactorial

• Denervation and resulting atony in gastric

remnant (Frederic et al.)

• Effect of vagotomy in proximal and distal

stomach

• Loss of vagal suppression on ectopic

intestinal pacemaker

• Associated procedures

Neuroendocrine and molecular factors

• Hyperglycemia

• Autonomic neuropathy

• Surgical stress-catecholamines

• Low motilin(absence of duodenum)

• Damage to ICC

• Hypothyrodism

Evaluation

• History

• Abdominal distention, Succussion

splash

• Clues to other etiologies

• Lab Tests

Evaluation

• EGD or Barium study– Rule out gastric outlet obstruction

Evaluation

• Gastric Scintigraphy– Gold standard– 99M Tc Sulfur colloid bound to solid food– Lack of standard criteria between institutions

• T1/2 or time intervals• Different diagnostic criteria determined at each

institution– Delay of 2 SD vs. 1.5 SD vs. 1 SD

• Different Meals• Different patient positions

Gastric scintigraphy

Wu D J Y et al. BMJ Case Reports 2009;2009:bcr.06.2009.1986

©2009 by BMJ Publishing Group Ltd

Problems with Scintigraphy

• Radiation exposure• Expensive• Lack of standardization

– differences in meals used– patient positioning– frequency and duration of imaging– Differences in quantitative data reported

• T1/2, rate of emptying, retention at different time points

• Lack of normal values

Wireless Motility capsule

WMC

1. Gastric emptying time

2. Small bowel transit time

3. Colonic transit time

4. Whole gut transit time

5. Amplitude of distal antral and duodenojejunal

contractions

6. Amplitude of phasic contractions of colon

7. Intragastric acidity

Breath test

• 13C-labelled octanoate incorporated in a solid meal

• Metabolised to 13C02

• 13C-spirulina

Complementary modalities

• Antroduodenal Manometry

• Electrogastrography

Treatment

• Correct fluid, electrolyte, and nutritional

deficiencies;

• Identify and rectify the underlying cause

of gastroparesis;

• Reduce symptoms-Ryle’s tube

Dietary Recommendation

• Increasing liquid nutrient content of the

meal

• Minimized fats and fiber intake

• Restricted meal size

• Alcohol to be avoided

Prokinetic Agents

• Enhance antral contractility

• Correct gastric dysrhythmias

• Improve antroduodenal coordination

Metoclopramide

• Antiemetic effect: D2,5-HT3

antagonism

• Prokinetic effect: +Ach release

• 5-HT4 receptor agonist

– Increase LES pressure/fundic tone

– Increase antral contractions

• Prokinetic effect limited to proximal GIT

• Effective for short term treatment

• Parenteral form available

• Nine trials

Pa rkman HP, Ha s l e r WL, F i s h e r RS . Ame r i c a n

Gastroenterological Association technical review on the

diagnosis and treatment of gastroparesis. Gastroenterology

2004; 127: 1592-1622

Erythromycin

• Gastroduodenal receptors of motilin

• + Antral contractility, Premature phase

III MMC

• Parenteral-most effective

• Narrow therapeutic window

Domperidone

– Benzimidazole derivative

– Dopamine 2 antagonist

– Promotility effect in upper GI tract

– Doesn’t cross blood-brain barrier

• Fewer central side effects

– Hyperprolactimemia, breast engorgement,

galactorrhea

Levosulpiride

• Selective D2 blocker, moderate 5HT4

agonist• Superior than placebo• Superior to Domperidone and

Metoclopramide in functional dyspepsia

Mansi C, Savarino V, Vigneri S, et al. Gastrokinetic effects of levosulpiride in dyspeptic patients with diabetic gastroparesis.Am J Gastroenterol

1995; 90: 1989±93.

Antiemetic Agents

• May be needed for additional nausea relief

• Role in gastroparesis not well established

Botulinum Toxin

• Intrapyloric injection

Gastric emptying(decreased release of excitatory transmitter)

• No controlled study

Refractory Gastroparesis

• Combination therapy• Gastrostomy/Jejunostomy• Gastric electric stimulation

Potentiate intrinsic slow waves

and phase III contractions

Surgical options

• In retractable cases as last resort• Subtotal or completion gastrectomy• Small uncontrolled series• Forstner-Barthell et al: Largest series

60 patients 40 symptomatic improvements

• No definite winner

Take Home Message

• Etiology and pathogenesis not well explained

• Diet and lifestyle alterations, prokinetics and

anti-nausea medications are the mainstay of

therapy

• Novel medications and device are currently

being studied and offer promise

• Evidence based investigation required

Thank You