FOR HEALTHCARE PROVIDERS - GASTROPARESIS

Gastroparesis is frequently misunderstood and underdiagnosed. It has been estimated to afflict 1.8% of the community while only 0.02% have been diagnosed.

The cardinal symptoms of gastroparesis (nausea, vomiting, bloating, early satiety, postprandial fullness and upper abdominal pain) are often confused with biliary colic and gallbladder dyskinesia.

Patients typically evolve to a carbohydrate rich diet as protein and fat empty poorly. This can result in a hyper-insulinemic state with fatty liver and weight gain, rather than weight loss. Therefore, weight loss should not be a necessary part of the diagnostic criteria.

Upper abdominal pain can be a very challenging part of the clinical picture. Gastric distension can increase wall tension, decrease perfusion and cause crampy upper abdominal pain. While narcotics should be avoided, their use should not preclude referral.

After obstruction is ruled out by upper gastrointestinal series (UGI) or esophagogastroduodenoscopy (EGD), gastric emptying scintigraphy confirms the diagnosis. It is important to get a 4-hr study for solids as insurance may not approve procedures without this information.

First line therapy should include dietary modification, glucose control and, if possible, narcotic cessation.

Pharmacologic therapy includes prokinetic agents (metoclopramide, erythromycin, and/or domperidone), antiemetics (promethazine and/or ondansetron), and antacids (omeprazole, pantoprazole, etc.). While these often fail and can be poorly tolerated, they should be tried prior to referring for surgery.

In a recent study of 1,423 patients, only 4% rated that they were satisfied with available treatment. Furthermore, patients reported they would accept a median 13.4% risk of sudden death by taking a hypothetical medication, if it meant it could cure symptoms.

Patients have good surgical options. After 1) ruling out obstruction with UGI or EGD and 2) demonstrating delay for solids on gastric emptying study, refer gastroparesis patients that have failed both first line and pharmacologic therapy.

Consistent with published recommendations, Dr. Hughes now starts with pyloroplasty since only about 1/3 of patients need to go on to gastric stimulation. With time, we hope to be able to identify this 1/3 up front so we can offer simultaneous pyloroplasty and gastric stimulator placement. Currently, we try to have patients wait 3 months following pyloroplasty before proceeding with gastric stimulation. Gastric stimulation appears more effective with dealing with nausea +/- vomiting refractory to pyloroplasty than bloating, early satiety and pain.

Dr. Hughes also places gastric stimulators as a laparoscopic outpatient procedure that takes only about 1 hour. He programs the generator to its lowest settings. We then see the patient in clinic every 1-2 months for adjustments as needed. Having had the pyloroplasty first, we do not need to increase the stimulator as high as we would have without pyloroplasty.

It is also important to note that Dr. Hughes is the only surgeon currently in the world performing these surgeries in an ambulatory surgical center (ASC). This is significant for those patients with any out-of-pocket costs (e.g. deductibles, coinsurance, or cash pay) as the procedures are significantly less expensive at an ASC than at a hospital.