Gastroparesis And Dyspepsia

Patients with severe exacerbation of symptoms should be hospitalized and may require nasogastric suction. Intravenous fluids should be provided, and metabolic derangements (ketoacidosis, uremia, hypo/hyperglycemia) corrected. Parenteral nutrition may become necessary in cases of malnutrition. Bezoars may be mechanically disrupted during endoscopy, followed by gastric decompression to drain residual nondigestible particles. Erythromycin at a dose of 3 mg/kg body weight intravenously every 8 h appears to be effective in accelerating gastric emptying (56). A week's treatment with oral erythromycin, 250 mg, t.i.d., is worthwhile once patients start to tolerate oral intake of food. Since both liquids and homogenized solids are more readily emptied from the stomach than solids, liquid or blenderized food will be better tolerated. Frequent monitoring of blood glucose levels is essential during this phase. Rarely, it is necessary to bypass the stomach with a jejunal feeding tube if the motor dysfunction is limited to the stomach and there is no response to prokinetic therapy. This procedure should be preceded by a trial for a few days of nasojejunal feeding with infusion rates of at least 60 ml iso-osmolar nutrient per hour. Jejunal tubes are best placed by laparoscopy or mini laparotomy rather than via percutaneous endoscopic gastrostomy tubes. Such tubes allow restoration of normal nutritional status but they are not without adverse effects. There is no evidence to suggest that gastrectomy relieves symptoms or enhances quality of life. Patients with gastroparesis often have concomitant small intestinal denervation which is likely to cause persistent symptoms after gastrectomy (32,66).

If the patient remains symptomatic, other prokinetic agents may be considered as adjuncts. In the USA, the only available medication is metoclopramide, a peripheral cholinergic and antidopaminergic agent. During acute administration, it initially enhances gastric emptying of liquids in patients with diabetic gastroparesis, but its symptomatic efficacy is probably related with its central antiemetic effects. However, its long term use is restricted by a decline in efficacy and by a troubling incidence of central nervous system side effects.

TABLE 3 Commonly Performed Autonomic Tests

Test

Physiologic functions tested

Rationale

Comments/pitfalls

Sympathetic function

1. Thermoregulatory sweat test (% surface area of anhidrosis)

2. Quantitative sudomotor axon reflex test (sweat output latency)

3. Heart rate and blood pressure responses

Orthostatic tilt test

Postural adjustment ratio Cold pressor test

Sustained hand grip

4. Plasma norepinephrine response to: Postural changes

Intravenous edrophonium

Parasympathetic Function

1. Heart rate (RR) variation with deep breathing

2. Supine/erect heart rate

Preganglionic and postganglionic cholinergic Postganglionic cholinergic

Adrenergic Adrenergic Adrenergic Adrenergic

Postganglionic adrenergic

Postganglionic adrenergic

Parasympathetic Parasympathetic

3. Valsalva ratio (heart rate, max./min.) Parasympathetic

4. Gastric acid secretory or plasma pancreatic polypeptide response to modified sham feeding or hypoglycemia

5. Nocturnal penile tumescence

6. Cystometrographic to bethanechol

Parasympathetic

Pelvic parasympathetic Pelvic parasympathetic

Stimulation of hypothalamic temp. control centers Antidromic stimulation of peripheral fiber by axonal reflex

Baroreceptor reflex Baroreceptor reflex Baroreceptor reflex Baroreceptor reflex

Baroreceptor stimulation

Anticholinesterase "stimulates" postganglionic fiber at prevertebral ganglia

Vagal afferents stimulated by lung stretch

Vagal stimulation by change in central blood volume vagal Stimulation of by change in central blood volume stimulation of Vagal nuclei by sham feeding or hypoglycemia

Integrity of S2-4

Increase in intra-vesical pressure suggests denervation supersensitivity

Cumbersome, whole body test

Needs specialized facilities

Impaired responses if intra-

vascular volume is reduced Impaired responses if intra-

vascular volume is reduced Impaired responses if intra-

vascular volume is reduced Impaired responses if intra-vascular volume is reduced

Moderate sensitivity, impaired response if intravascular volume is reduced False-negatives caused by contributions to plasma norepinephrine from many organs

Best cardiovagal test available, but not a test of abdominal vagus Cardiovagal test

Cardiovagal test

Abdominal vagal test, critically dependent on avoidance of swallowing food during test Plethysmographic technique requiring special facilities Tests parasympathetica supply to response bladder, not bowel

Source: From Ref. 74.

"Botulinum toxin" has been injected into the pylorus in several uncontrolled studies which suggested benefit of the intervention (67). However, this has not been borne out by controlled clinical trials (68).

"Gastric electrical stimulation" is still controversial despite approval by the Food and Drug Administration as a humanitarian use device after a controlled study showed decreased vomiting frequency in diabetic gastroparesis when the stimulator was switched on. Gastric emptying was not altered in this study and the mechanism of symptomatic benefit is unclear (69).

"Diabetic diarrhea" is treated symptomatically with loperamide, 2-8 mg per day. Second line approaches are clonidine, 0.1 mg orally (70) or by patch in patients who do not experience significant postural hypotension, and subcutaneous octreotide, 25-50 mg subcutaneously 5-10 min before meals (71).

"Constipation" is typically treated with osmotic and stimulant laxatives. One should avoid lactulose because of potential impact on glycemic control, and magnesium compounds in patients with impaired renal function because of risk of magnesium retention. Polyethylene glycol osmotic laxatives are useful (up to 17 g in 8 ounces of water per day) though care needs to be taken to avoid dehydration or sodium overload in patients requiring regular dosing. Pelvic floor disorders should be excluded before embarking on long-term polyethylene glycol therapy.

"Incontinence" may require physical medicine and biofeedback approaches to enhance rectal sensation, and to strengthen the external anal sphincter. In the presence of a significant pudendal neuropathy or sensory loss, biofeedback may not work and the patient may have a better quality of life with a descending colostomy.

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