Endoscopic Approaches to Gastroparesis
Endoscopic Approaches to Gastroparesis
Not infrequently, patients with severe gastroparesis are seen in emergency care, with repeated vomiting, de-hydration and malnutrition. In the acute setting, the aim is to restore fluids and electrolytes, bring serum glucose levels to the normal range and address possible comorbidities. After these acute medical tenets have been accomplished, attention is directed to long-term palliation.
Dietary manipulation has been demonstrated to improve upper gastrointestinal symptoms in patients with gastroparesis in a recent trial. General recommendations include a small-particle, low-fat and low-fiber diet. The avoidance of fiber has the specific aim of decreasing bezoar formation. If oral intake is not adequate, then enteral feedings through a jejunal tube or parenteral nutrition may be necessary.
Metoclopramide, a dopamine receptor antagonist, is the only US Food and Drug Administration (FDA)-approved drug for gastroparesis. Metoclopramide increases the tone and amplitude of antral contractions, thus improving gastric emptying. Restlessness, drowsiness and fatigue can occur in up to 10% of the patients. Tardive dyskinesia is the most feared complication of long-term use of metoclopramide, with reported incidence of about 1%. Treatment duration is recommended to be no longer than 12 weeks. Dosage should be titrated to the lowest possible that controls symptoms and drug holidays are recommended. In patients unable to take metoclopramide, domperidone – a more selective dopamine antagonist – may be obtained under US FDA authorization. The effect of domperidone and metoclopramide had been shown to be similar. Domperidone has the potential to prolong corrected QT intervals and can induce cardiac arrhythmias. Erythromycin – a motilin agonist – is also an effective prokinetic, especially for short-term use. In the long term, there is down-regulation of the motilin receptor, leading to tachyphylaxis and decreased efficacy of the drug. Antiemetic drugs that do not accelerate gastric emptying (antihistamines, phenothiazines, 5-HT3 receptor antagonists) can also be indicated in an off-label basis. For pain control, tricyclic antidepressants may be employed; even though amitriptyline has anticholinergic properties and can delay gastric emptying.
Novel potential drugs for the treatment of gastroparesis are under investigation, including ghrelin receptor agonists or muscarinic antagonists.
There is considerable concern about the long-term use of prokinetics. Also, the efficacy of medical treatment is modest, especially for more advanced cases. This has been leading to frustration in both patients and physicians, with increasing referral for endoscopists and surgeons to play a role in the multidisciplinary care of gastroparesis patients.
Medical Management
Emergency Care
Not infrequently, patients with severe gastroparesis are seen in emergency care, with repeated vomiting, de-hydration and malnutrition. In the acute setting, the aim is to restore fluids and electrolytes, bring serum glucose levels to the normal range and address possible comorbidities. After these acute medical tenets have been accomplished, attention is directed to long-term palliation.
Dietary
Dietary manipulation has been demonstrated to improve upper gastrointestinal symptoms in patients with gastroparesis in a recent trial. General recommendations include a small-particle, low-fat and low-fiber diet. The avoidance of fiber has the specific aim of decreasing bezoar formation. If oral intake is not adequate, then enteral feedings through a jejunal tube or parenteral nutrition may be necessary.
Pharmacologic
Metoclopramide, a dopamine receptor antagonist, is the only US Food and Drug Administration (FDA)-approved drug for gastroparesis. Metoclopramide increases the tone and amplitude of antral contractions, thus improving gastric emptying. Restlessness, drowsiness and fatigue can occur in up to 10% of the patients. Tardive dyskinesia is the most feared complication of long-term use of metoclopramide, with reported incidence of about 1%. Treatment duration is recommended to be no longer than 12 weeks. Dosage should be titrated to the lowest possible that controls symptoms and drug holidays are recommended. In patients unable to take metoclopramide, domperidone – a more selective dopamine antagonist – may be obtained under US FDA authorization. The effect of domperidone and metoclopramide had been shown to be similar. Domperidone has the potential to prolong corrected QT intervals and can induce cardiac arrhythmias. Erythromycin – a motilin agonist – is also an effective prokinetic, especially for short-term use. In the long term, there is down-regulation of the motilin receptor, leading to tachyphylaxis and decreased efficacy of the drug. Antiemetic drugs that do not accelerate gastric emptying (antihistamines, phenothiazines, 5-HT3 receptor antagonists) can also be indicated in an off-label basis. For pain control, tricyclic antidepressants may be employed; even though amitriptyline has anticholinergic properties and can delay gastric emptying.
Novel potential drugs for the treatment of gastroparesis are under investigation, including ghrelin receptor agonists or muscarinic antagonists.
There is considerable concern about the long-term use of prokinetics. Also, the efficacy of medical treatment is modest, especially for more advanced cases. This has been leading to frustration in both patients and physicians, with increasing referral for endoscopists and surgeons to play a role in the multidisciplinary care of gastroparesis patients.
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