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Gastroparesis

Dr. Rajalakshmi VK (AIIMS)MBBS

August 14, 2020

August 14, 2020

Gastroparesis
Gastroparesis

The stomach is a hollow organ—a kind of muscular pouch. The food that we swallow enters the stomach, where it is ground into tiny pieces by rhythmic contractions of the stomach muscles—these contractions cause a continuous churning. Once the food is ground properly, it is emptied from the stomach into the small intestine slowly—in a metered fashion.

Here's what happens in the metering process: while the part of the stomach which stores food becomes relaxed, another part which pushes the food into the small intestine gets pressurised. This helps the stomach to store and empty food at the same time. The metering process is controlled by the opening and closing of the pylorus: a muscular opening that joins the stomach into the small intestine.

When the stomach contractions are weak, the stomach cannot grind the food thoroughly and cannot empty it into the intestine properly, leading to gastroparesis.

Gastroparesis is a disease in which the stomach cannot empty itself of food in a normal fashion. This is a common condition in people who have had diabetes for a long time, but it may also occur in other situations. It's thought to be the result of a problem with the nerves and muscles that control how the stomach empties itself of food. (If these nerves are damaged, the muscles of your stomach may not work properly and the movement of food can slow down.)

The symptoms of gastroparesis may include heartburn, nausea and vomiting, and feeling full quickly when eating. Treatment may involve the use of medications to relieve the symptoms or surgery to correct the abnormalities.

Gastroparesis symptoms

The common symptoms of gastroparesis are:

Gastroparesis complications

If gastroparesis is not treated, it can lead to several problems, some of which include:

  • The person can have dehydration due to repeated vomiting
  • The person can suffer from malnutrition as the body is unable to get enough nutrients
  • The person can suffer from gastro-oesophageal reflux disease (GERD) as the stomach acid leaks out from the stomach into the food pipe (oesophagus).
  • The person can also experience a sudden spike in their blood glucose levels when the food finally leaves the stomach and enters the small intestine. This can be harmful to diabetics. 
  • Food that stays in the stomach for too long can ferment and allow bacteria to grow in there. This food can also harden into a solid mass called a bezoar, which can later cause blockage in the stomach thus preventing the food from passing into the small intestine

Gastroparesis causes

Gastroparesis is typically caused due to an injury or damage to the vagus nerve. In most cases, diabetes is the reason for the damage to the vagus nerve as well as other nerves which supply the wall of the stomach. The vagus nerve is one of the nerves that control the muscles of the stomach and small intestine. 

When the vagus nerve gets damaged, the muscles of the stomach and small intestine stop functioning normally, thus the food is unable to move through the digestive tract. Other causes of gastroparesis include:

  • Disorders that involve the smooth muscles of the stomach can lead to gastroparesis. These diseases include amyloidosis (deposit of protein fibres in tissues and organs) and scleroderma (a skin disorder which affects the skin, blood vessels, skeletal muscles and internal organs).
  • Eating disorders such as anorexia or bulimia can lead to gastroparesis.
  • Surgery related to the stomach and vagus nerve can also result in gastroparesis.
  • Extreme tiredness without any underlying medical condition, such as chronic fatigue syndrome can result in gastroparesis.
  • Long-term use of medications such as narcotics can result in gastroparesis.
  • People with nervous system disorders such as abdominal migraine and Parkinson's disease or those with metabolic disorders such as hypothyroidism may be at risk of gastroparesis.
  • Viral infections such as viral gastroenteritis can eventually lead to gastroparesis.

Gastroparesis prevention

Gastroparesis cannot be prevented as the exact cause is still unknown. However, people with diabetes should keep their sugar levels under control to prevent the condition. Avoid strong medications such as narcotics as it can trigger gastroparesis.

Gastroparesis diagnosis

After taking a proper medical history and doing a physical examination, the doctor would prescribe certain blood tests to diagnose the condition. The tests that are used to diagnose gastroparesis include:

  • 4-hour solid gastric emptying study: This test is done to determine the time that food takes to move through a person’s stomach. In this test, the technologist asks the person to eat a meal tagged with a radioactive isotope. After having the meal, a one-minute image of the stomach is taken. The scans are done again after one hour, two hours and four hours. 
  • SmartPill: SmartPill is a capsule that contains a small electronic device which has a receiver that is worn on the hand. The pill is ingested with special food. As the pill moves through the digestive tract, it sends information to the receiver on how quickly the food is travelling through the digestive tract.
  • Blood test: Complete blood count is done to find out the cause behind dehydration, malnutrition, infection and blood sugar levels.
  • Barium X-ray: Barium X-ray is done by making the patient drink barium, which coats the oesophagus, stomach, and small intestine. Then the doctor takes an X-ray of the entire region to look for any abnormalities.
  • Gastric emptying breath test: Gastric emptying breath test is a non-radioactive test that helps in measuring the rate at which the stomach empties after having a meal that has a chemical element called the 13C isotope added to it.
  • Gastric manometry: Gastric manometry is done to check the electrical and muscular activity of the stomach, and also to figure out the rate at which the food is digested.
  • Electrogastrography: In electrogastrography, the doctor measures the electrical activity in the stomach by using electrodes on the skin.
  • Ultrasound: Ultrasound is done to look at any problems inside the stomach.
  • Endoscopy: Endoscopy is done to look at the lining of the stomach—it uses a small camera at the end of an endoscope (a thin tube that is guided down the patient's throat) to look inside the organ.

Gastroparesis treatment and management

Most treatment options for gastroparesis focus on managing the condition and keeping it under control. These are the main treatment plans used to treat and manage gastroparesis:

  1. Maintain blood sugar levels to manage gastroparesis
  2. Changes in diet and lifestyle for gastroparesis
  3. Drug therapy for gastroparesis
  4. Per oral pyloromyotomy (POP) for gastroparesis
  5. Surgical treatment of gastroparesis
  6. Parenteral nutrition in gastroparesis

Maintain blood sugar levels to manage gastroparesis

People who have diabetes should try to control their blood glucose levels to reduce the problems of gastroparesis, as hyperglycemia (high blood glucose levels) delays the emptying of food from the stomach.

Changes in diet and lifestyle for gastroparesis

A person with gastroparesis would have to make some necessary changes in their diet and lifestyle in order to manage the symptoms of gastroparesis. The person needs to have an adequate amount of nutrients, calories, and fluids to prevent malnutrition and dehydration.

The required dietary changes include:

  • Instead of two or three large meals, eat five to six small, nutritious meals a day.
  • Consume foods rich in fibre and low on fat such as low-fat broths or clear soups, fruits and vegetable juices (without sugar or sweeteners).
  • Chew your food properly before swallowing.
  • Avoid eating foods that are hard and difficult to digest. Instead, eat soft and well-cooked foods.
  • Do not consume alcohol and carbonated, fizzy drinks as they tend to increase blood sugar levels and also cause dehydration. Instead, drink lots of water and liquids that contain glucose and electrolytes such as oral rehydration salts solution.
  • Do not lie down immediately after a meal. Do some gentle physical activity such as taking a small walk after a meal

For people with moderate to severe symptoms, doctors may recommend consuming only liquids or well-cooked and mashed solid foods.

Drug therapy for gastroparesis

Some medicines used to treat the symptoms of gastroparesis are:

  • Erythromycin: Erythromycin is an antibiotic which helps in the contraction of the stomach which, in turn, helps to move the food out.
  • Antiemetics: Drugs like bismuth subsalicylate are antiemetics which help in controlling nausea and vomiting. 
  • Metoclopramide: Metoclopramide increases the ability of the stomach wall muscles to contract, thus improving gastric emptying. It also relieves nausea and vomiting.
  • Domperidone: Domperidone increases the contraction of the muscles present in the wall of the stomach. This improves gastric emptying. 
  • Pain medications: Non-narcotic pain medicines such as ibuprofen and acetaminophen may reduce pain in your abdomen due to gastroparesis.

Per oral pyloromyotomy (POP) for gastroparesis

Per oral pyloromyotomy (POP) is a procedure in which the doctor inserts an endoscope—a long, thin, flexible tube—into the patient’s stomach through the mouth. The doctor then makes a cut on the pylorus, which is the opening of the stomach to the intestine. This helps the food to move from the stomach to the small intestine with greater ease.

Surgical treatment of gastroparesis

People who complain of symptoms of gastroparesis like nausea and vomiting even after taking medicines may have to undergo surgery. The surgery may involve one of the following procedures:

  • Gastric electrical stimulation: Gastric electrical stimulation involves sending mild electric shocks to the stomach muscles. During this procedure, the doctor inserts a small device called a gastric stimulator into the patient's abdomen. The stimulator has two leads that are attached to the stomach to provide a mild electric shock. This mild shock helps in controlling vomiting.
  • Gastric bypass: If the patient does not get relief from gastroparesis through medicines, the doctor may perform a gastric bypass (a type of bariatric surgery).
    In a gastric bypass, the small intestine is divided in half and the lower end of the intestine is attached directly to the small pouch present in the top part of the stomach. This prevents overfilling of the stomach, thus allowing the food to move out of the stomach easily.
    This procedure is more effective than oral drugs and gastric stimulator.
  • Feeding tube: In severe case of gastroparesis, the doctor would insert a feeding tube or a jejunostomy tube from the abdomen to the small intestines. The churned food is then put into the tube, which goes directly into the small intestine. This helps the food to get absorbed more quickly as the tube bypasses the stomach and delivers the liquid food directly into the jejunum (part of the small intestine).

Parenteral nutrition in gastroparesis

Parenteral nutrition is provided by placing a catheter into a vein in the chest. It is one of the ways that help in delivering liquid nutrients directly to the bloodstream. Parenteral nutrition helps in treating the condition until either a feeding tube is placed or another surgical procedure is performed by the doctor.



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