Gastroparesis K31.88

Gastroparesis has been reported in the literature since the mid-20th century (Usai- Satta 2020).

Dysfunction of the pylorus in diabetic gastroparesis was first described by Meinin et al. in 1986.

Since 1993, the diagnostic test developed by Ghoos et al. to measure gastric emptying rate using a carbon-labeled octanoic acid breath test has been used (Usai- Satta 2020).

Gastroparesis (GE / Gp) refers to a symptom or set of symptoms (Schol 2021) due to delayed gastric emptying without the presence of mechanical obstruction (Grover 2019). The symptoms themselves must have been present for at least 3 months to be considered Gp (Schol 2021).

Gastroparesis is one of the enteritic ganglionitides (Keller 2021).

One differentiates between

- a. True gastroparesis:

This is defined as a form of the disease with typical symptoms and scintigraphically proven delayed gastroparesis.

- b. Probable gastroparesis:

In this case, in addition to the typical symptoms, there is endoscopically proven delayed Gp.

- c. Possible gastroparesis:

This is manifested by typical symptoms or an asymptomatic delayed Gp (Grover 2019).

Waseem et al (2009) differentiates between three different clinical courses:

- Mild Gp:

There is no loss of body weight and symptoms are easily managed.

- Moderate Gp:

Frequent but not daily symptoms are found, which are well treatable with antiemetics, prokinetics, dietary changes and control of glucose

- Severe Gp:

In this, there is the occurrence of daily symptoms, weight loss and malnutrition despite medical treatment. The patient requires frequent medical treatment and hospitalization (Waseem 2009).

The severity of symptoms can be calculated by the GCSI (Gastroparesis Cardinal Symptom Index):

The GCSI consists of 9 items grouped into three subscales, assessed in the last two weeks:

- nausea / vomiting

- postprandial fullness / early feeling of satiety

- flatulence

For each item, the patient assigns a score from 0 to 5. The higher the total score, the higher the severity of clinical manifestations (Waseem 2009).

Gp is a relatively common but poorly known clinical condition (Usai- Satta 2020) that is often undiagnosed, particularly the malignancy-associated form (Tilg 2021).

According to Schol (2021), the epidemiology of the disease is as yet unknown (Schol 2021). Grover (2019) describes the age-adjusted incidence per 100,000 persons as 2.4 for males and 9.8 for females, with numbers increasing with age.

However, Gp can also occur, albeit less frequently, in childhood (Rodeck 2008)

Gastroparesis is rarely found in the context of diabetes mellitus as parasympathetic damage (Herold 2022). It has been shown that only about 1 - 5% of all diabetics are affected by diabetic gastroparesis (DG) (Grover 2019).

Women are significantly more likely to develop the disease than men, accounting for 82% (Schol 2021)

Gastroparesis is a parasympathetic injury that can occur in the context of the following diseases (Herold 2022):

- Diabetes mellitus

Diabetes is considered a prototypical cause (Grover 2019). Type- 1 diabetics are particularly affected (Schol 2021).

- chronic pancreatitis (Kasper 2015).

- end-stage renal disease

- mesenteric ischemia

- myopathies

- apoplexy

- Muscular dystrophies such as Duchenne muscular dystrophy, myotonic dystrophy

- Infectious diseases such as viral diseases caused by CMV(cytomegaloviruses), EBV(Epstein-Barr virus), VZV(varicella zoster viruses), etc. (Usai-Satta 2020)

- postoperatively after e.g. gastric resection, vagotomy, bariatric surgery, lung transplantation, pancreaticoduodenectomy etc.

- as post-infectious disease after viral gastrointestinal infections (Schol 2021)

- Connective tissue diseases including amyloidosis, dermatomyositis, scleroderma, Sjögren's syndrome, LES (Lambert- Eaton-Rooke syndrome), polymyositis, etc.

- Eating disorders such as anorexia nervosa, bulimia

- malignant diseases such as lymphoma, pancreatic carcinoma, paraneoplastic syndrome (Usai- Satta 2020)

- Idiopathic (most common cause at over 50% [Grover 2019]).

- Nervous system disorders such as Parkinson's disease, multiple sclerosis, myasthenia gravis, Guillain- Barre syndrome, dysautonomia (Usai- Satta 2020)

- Amyloid neuropathy (Schol 2021)

- Medications such as opioids (Schol 2021), anticholinergics, 2nd generation antipsychotics, tricyclic antidepressants, calcium channel blockers, cannabis , etc. (Usai- Satta 2020)

- Food allergy (Rodeck 2008).

The leading symptoms are

- Nausea (most common symptom, occurs in approximately 95% of patients [Grover 2019]).

- Vomiting (Schol 2021) within 1 h of food intake (Kasper 2015).

Other symptoms may include:

- Feeling of fullness

- feeling of pressure in the upper abdomen

- postprandial hypoglycemia (Herold 2022)

- early feeling of satiety (Schol 2021)

- severe flatulence in about 40% (Grover 2019)

- weight loss (Tilg 2021)

Diagnosis is usually initially performed sonographically and endoscopically (Schol 2021) and is then supplemented by special diagnostics such as the 13C-octanoic acid breath test or gastric emptying scintigraphy (Herold 2022).

Mechanical obstruction of the gastrointestinal passage should be excluded with certainty during diagnosis (Schol 2021).

Sonography

Sonography can be used to assess the movements of the antrum wall, patterns of transpyloric flow, and the diameter of the gastric antrum (Schol 2021).

Gastrointestinal passage (ÖGD) / CT / MR enterography

These examinations are primarily used to rule out mechanical obstruction (Rodeck 2008 / Tilg 2021).

Gastroscopy

Here, in addition to gastric juice residues (Kasper 2015), food retention is typically found (Schol 2021).

Gastric emptying scintigraphy (GES).

This examination is currently considered the gold standard. It can be used to assess the transport of a meal labeled with Technitium 99 m through the upper gastrointestinal tract (Usai- Satta 2020).

Gastric emptying disorder is defined scintigraphically as:

- Gastric retention > 10 % after 4 h resp.

- Gastric retention > 60 % after 2 h (Tilg 2021).

In mild Gp, retention of 10 - 15 % after 4 h is found, in moderate Gp, retention of 15 - 35 % after 4 h and in severe GP, retention of > 35 % after 4 h (Tilg 2021).

Double-contrast radiography

This is primarily used for differential diagnostic exclusion of e.g. a hiatal hernia, an ileus etc.. In the case of a Gp, reduced peristalsis, gastric dilatation and retention of gastric contents are found (Usai- Satta 2020).

Physical examination

Body Mass Index should be calculated and abdominal scars noted. Examination of the skin and mucous membranes may reveal evidence of connective tissue disease (Usai- Satta 2020).

Auscultatory evidence of a succussive murmur can be heard when the patient moves abruptly sideways (Kasper 2015).

Gastric emptying breath test (GEBT).

The 13- C- octanoic acid gastric emptying breath test is a simple and inexpensive diagnostic test. However, the test is unreliable in patients with pancreatic insufficiency, obstructive lung disease, and malabsorption (Usai- Satta 2020).

Wireless Motility Capsule (WMC).

This makes it possible to transmit retention time, temperature, pH and pressure. A retention time in the stomach of more than 5 h defines a delayed gastric emptying (Usai- Satta 2020).

- Complete blood count

- electrolytes

- glucose

- creatinine

- urea

- TSH

- Hb- A1c- value in diabetics

- Serological markers in underweight patients

- Determination of specific antibodies in the presence of an autoimmune disease (Usai- Satta 2020)

In many intestinal mobility disorders, including Gp, there is often a reduction in the number of ICCs (Intestinal Cells of Cajal) or an altered architecture and distribution of the ICC networks. However, a direct causal relationship has not yet been proven with certainty (Keller 2021).

- Functional dyspepsia (Kasper 2015)

- chronic pancreatitis

- dumping syndrome

- malignant diseases

- gastric outlet stenosis

- ileus (Usai- Satta 2020)

- Cachexia (Tilg 2021)

Treatment of a Gp consists primarily of:

- Symptom control

- Correction of nutritional deficiencies

- Maintenance of a certain body weight

- Therapy of the causes (Usai- Satta 2020).

Dietary changes

Dietary measures should be the primary focus (Tilg 2021).

Olausson (2014) points out a significant decrease in the symptomatology of gastroparesis by the so-called "small-particle diet", also called "intervention diet". This form of diet should consist of small, frequent, low-fat and low-fiber foods (Usai- Satta 2020).

The therapy of autonomic diabetic neuropathy can additionally be carried out with medication.

Here, the administration of metoclopramide (Tilg 2021) is recommended as a first step.

- Metoclopramide

This is a combined 5- HT4 agonist and a D2 antagonist. However, in up to 25% of cases, antidopaminergic side effects such as dystonia, sleep disturbances, and mood swings lead to limited use (Kasper 2015). It also usually shows a rapid loss of effect among them (Herold 2022), but a therapy trial is still recommended according to the guideline (Keller 2021).

Dosage recommendation: 3 - 4 x 10 mg / d about 10 - 15 min before meals (Tilg 2021).

If no improvement in symptoms can be achieved with metoclopramide, the administration of erythromycin is recommended (Tilg 2021).

- Erythromycin

This drug increases gastroduodenal motility by acting on receptors for motilin (Kasper 2015). But the motilin analog effect is mostly short term (Herold 2022), but the use is still recommended according to the guideline (Keller 2021).

Dosage recommendation: 3 x 250 mg / d before meals (Tilg 2021).

- Antiemetics

Here, ondansetron (trade name Zofran R) is recommended at a dosage of 4 - 8 mg 3 x / d.

(Lüllmann 2004 / Usai- Satta 2020).

In insulin-dependent diabetics, attention should be paid to any postprandial hypoglycemia that may occur and the injection-eating interval should be adjusted accordingly, and the injection may even be administered after food intake (Herold 2022).

In cases of refractory severe gastropathy, a jejunal feeding tube with CGMS (continuous glucose monitoring) or insulin pump therapy (CSII) may be necessary (Herold 2022).

Pyloroplasty

In severe and therapy-resistant courses, pyloroplasty may be indicated

(Usai- Satta 2020). In a 2015 retrospective study by Mancini et al, normalization of gastric emptying was shown in 60% of affected patients.

Gastric pacemaker

A gastric pacemaker is considered the ultimo ratio. The operation is possible in a few specialized clinics (Tilg 2021).

Gp leads to significant limitations and burdens on quality of life (Usai- Satta 2020). Patients with both definite, probable, and possible Gp had higher rates of hospitalization, and decreased life expectancy in a 2009 study by Jung.

The prognosis of gastroparesis depends on the cause of the disease (Schol 2021).

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