Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index

Esophageal distension parameters as potential biomarkers of impaired gastrointestinal function in diabetes patients

BACKGROUND

Gastrointestinal (GI) symptoms, such as nausea, vomiting, bloating, postprandial fullness, and abdominal pain, are frequent in patients with diabetes mellitus (DM). The pathogenesis is complex and multi-factorial. To determine easy accessible and valid biomarkers for disordered GI function in DM patients, we aimed to study esophageal mechanical parameters and their relation to symptoms typically arising from the digestive tract.

METHODS

Seventeen patients with longstanding DM and GI symptoms and 13 healthy controls were studied using ultrasound monitored esophageal distension. The sensory response was recorded and their symptoms registered. Biomechanical parameters, such as compliance and stiffness were computed from luminal diameters during distension based on the ultrasound images and from pressure data. Biomechanical and sensory parameters were correlated with the clinical data.

KEY RESULTS

Diabetes patients had reduced esophageal sensitivity compared with controls (P = 0.046). The esophageal compliance was reduced (P = 0.004) and the esophageal stiffness was increased (P = 0.004) in the diabetes patients. Among patients, both postprandial fullness/early satiety and bloating correlated negatively to the esophageal compliance parameters (all P < 0.05).

CONCLUSIONS & INFERENCES

Patients with long-standing DM and GI symptoms had reduced esophageal sensitivity together with reduced compliance and increased stiffness, which were correlated to the patients' GI symptoms. Biomechanical parameters obtained during distension may serve as biomarker for similar pathophysiologic effects of diabetes in the stomach and small bowel. They may contribute to our understanding of the pathophysiology underlying GI dysfunction and symptoms in patients with longstanding DM.

Diabetic gastrointestinal autonomic neuropathy: current status and new achievements for everyday clinical practice

Gastrointestinal symptoms occur frequently among patients with diabetes mellitus and are associated with considerable morbidity. Diabetic gastrointestinal autonomic neuropathy represents a complex disorder with multifactorial pathogenesis, which is still not well understood. It appears to involve a spectrum of metabolic and cellular changes that affect gastrointestinal motor and sensory control. It may affect any organ in the digestive system. Clinical manifestations are often underestimated, and therefore autonomic neuropathy should be suspected in all diabetic patients with unexplained gastrointestinal symptoms. Advances in technology have now enabled assessment of gastrointestinal motor function. Moreover, novel pharmacological approaches, along with endoscopic and surgical treatment options, contribute to improved outcomes. This review summarises the progress achieved in diabetic gastrointestinal autonomic neuropathy during the last years, focusing on clinical issues of practical importance to the everyday clinician.

Fatigue: a prevalent symptom in gastroparesis

BACKGROUND

Fatigue is seen in many medical conditions. Patients with gastroparesis may complain of fatigue.

AIM

The aim of this work is to first assess the prevalence and severity of fatigue in patients with gastroparesis, and secondly to correlate fatigue with symptoms, quality of life, and factors that may contribute to fatigue.

METHODS

One hundred and fifty-six patients with gastroparesis filled out questionnaires including the fatigue assessment instrument (FAI), patient assessment of upper gastrointestinal symptom severity index, patient assessment of upper gastrointestinal disorders-quality of life and hospital anxiety, and depression scale to evaluate for fatigue, symptoms, quality of life, and depression. Gastric emptying test and laboratory studies for hemoglobin, glycosylated hemoglobin, thyroid function (TSH), and inflammatory markers (CRP and ESR) were obtained.

RESULTS

Fatigue was reported by 93 % of patients. The mean total FAI score was 3.71 ± 0.2, with 51 % of patients having a score above 4, indicating severe fatigue. There were moderate correlations between fatigue and many symptoms of gastroparesis: upper abdominal discomfort (r = 0.446), upper abdominal pain (r = 0.422), loss of appetite (r = 0.329), bloating (r = 0.297), and abdominal distention (r = 0.265). Fatigue in patients using metoclopramide (3.5 ± 0.4) was similar to patients using domperidone (3.7 ± 0.5) or neither medicine (3.8 ± 0.3). Fatigue severity correlated with a decreased quality of life (r = -0.694, p < 0.001), increased depression (r = 0.339, p = 0.009), lower anxiety (r = -0.441, p < 0.001), and lower hemoglobin levels (r = -0.258, p = 0.005), but not to glycosylated hemoglobin, ESR, CRP, TSH, or gastric emptying.

CONCLUSIONS

Fatigue is an important significant symptom in patients with gastroparesis with a high prevalence and severity. Fatigue is correlated with many symptoms of gastroparesis, low hemoglobin, depression, inflammation, decreased quality of life, but not to severity of delayed gastric emptying or to medication use.

Minimally invasive surgical approach for the treatment of gastroparesis

BACKGROUND

Gastroparesis is a chronic disorder resulting in decreased quality of life. The gastric electrical stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy.

METHODS

A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI).

RESULTS

There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3% vs. 23%, p = 0.06) and in-hospital mortality rate (2.7% vs. 3%, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26%) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7%, mortality 0). In total, 57% of patients were treated with GES while only 43% had final treatment with gastrectomy. Of the GES group, 63% rated their symptoms as improved versus 87% in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100% symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12).

CONCLUSION

The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.

Evaluating symptom outcomes in gastroparesis clinical trials: validity and responsiveness of the Gastroparesis Cardinal Symptom Index-Daily Diary (GCSI-DD)

BACKGROUND

Patient-reported symptom scales are needed to evaluate treatments for gastroparesis. The Gastroparesis Cardinal Symptom Index-Daily Diary (GCSI-DD) was developed to assess daily symptoms of gastroparesis. This study evaluated the validity and responsiveness of the GCSI-DD in patients with gastroparesis.

METHODS

Symptomatic patients were started with a new treatment for gastroparesis. Patients completed the GCSI-DD each evening during a baseline week and for 8 weeks of treatment. Responders were defined based on patient and clinician global rating of change. Minimal important differences (MID) were estimated based on baseline to 4 week changes in symptoms scores for small improvements.

KEY RESULTS

Of 69 patients participating, 46 had idiopathic, 19 diabetic, and four postfundoplication gastroparesis. Excellent test-retest reliability was seen for GCSI-DD scores, and there were significant correlations between GCSI-DD scores and clinician ratings of symptom severity. Responders to treatment reported improvements in nausea [effect size (ES) = 0.42, P < 0.001], postprandial fullness, ES = 0.83, P < 0.001), bloating (ES = 0.34, P < 0.001), early satiety (ES = 0.53, P < 0.001), but lower responses for upper abdominal pain (ES = 0.29), and vomiting (ES = 0.22; P = 0.119). MIDs were 0.55 for nausea, 0.97 for excessive fullness, 0.63 for bloating, 0.77 for postprandial fullness, and 0.30 for abdominal pain. A composite score of four symptoms (Composite-1; nausea, bloating, excessive fullness, postprandial fullness) had ES of 0.61 and MID of 0.73. Composite-2 score (nausea, early satiety, bloating, abdominal pain) had a lower ES of 0.47.

CONCLUSIONS & INFERENCES

Symptoms of early satiety, nausea, postprandial fullness, and bloating were responsive to treatment for gastroparesis. A composite of these symptoms also demonstrates validity and responsiveness to treatment for gastroparesis, and may represent an acceptable endpoint for evaluating the effectiveness of medical treatments in clinical trials for gastroparesis.

Gastric emptying scintigraphy: is four hours necessary?

INTRODUCTION

Recommendations for gastric emptying scintigraphy (GES) suggest imaging over 4 hours to better define gastroparesis.

AIMS

To determine the value of defining delayed gastric emptying at time points earlier than 4 hours.

METHODS

GES was performed with ingestion of a liquid egg white meal with imaging at 0, 0.5, 1, 2, 3, and 4 hours. Patients completed the Patient Assessment of Gastrointestinal Symptoms questionnaire immediately before GES.

RESULTS

Of 1499 patients undergoing GES from September 2007 to January 2010 (76.2% were female, mean age of 45.5±0.5 y, 21.3% had diabetes, 9.5% had earlier gastric surgery), 160 (10.7%) had increased gastric retention at 1 hour (>90%), 404 (27%) had increased retention at 2 hours (>60%), 576 (38.4%) had increased retention at 3 hours (>30%), and 629 (42%) had increased retention at 4 hours (>10%). Gastric retention at 4 hours correlated with retention at 3 hours (r=0.890; P<0.001), 2 hours (r=0.738; P<0.001), and 1 hour (r=0.510; P<0.001). Symptoms correlated better with the gastric retention at later time points. The symptoms correlating with gastric retention at 4 hours included early satiety (r=0.170; P<0.01), vomiting (r=0.143; P<0.01), feeling excessively full after meals (r=0.123; P<0.01), and loss of appetite (r=0.122; P<0.01).

CONCLUSIONS

Gastric retention at 4 hours correlates well with gastric retention at 3 hours, good at 2 hours, but only fair with gastric retention at 1 hour. Gastric retention at 1 hour may miss 36% of patients found to have delayed gastric emptying at 4 hours. Symptoms (early satiety, vomiting, feeling excessively full after meals, and loss of appetite) correlated better with the gastric retention at later time points.

Nausea and vomiting in diabetic and idiopathic gastroparesis

BACKGROUND

Nausea and vomiting are frequent symptoms of gastroparesis. The aim of this study was to characterize nausea and vomiting in gastroparesis and to compare nausea and vomiting in patients with diabetic and idiopathic gastroparetics. We also quantitated the number of episodes of vomiting per day and the hours of nausea per day.

METHODS

Patients diagnosed with gastroparesis at Temple University Hospital between May 2009 and December 2010 completed the Patient Assessment of Upper GI Symptoms questionnaire along with questionnaires about nausea and vomiting.

KEY RESULTS

A total of 157 patients [43 diabetic (DG) and 114 idiopathic gastroparetics (IG)] comprised the study group. Nausea was present in 91% of DG and 90% of IG (P = 0.822). Nausea symptom severity score was 3.51 ± 0.24 in DG and 3.42 ± 0.15 in IG (P = 0.362). DG patients reported 8.1 ± 1.2 compared to 7.9 ± 0.8 in IG (P = 0.44). Vomiting was present in 72% of DG and 55% of IG (P = 0.083). Vomiting symptom severity score was 2.69 ± 0.34 in DG and 1.83 ± 0.21 in IG (P = 0.010). DG patients reported 7.3 ± 1.7 vomiting episodes per day compared to 3.5 ± 0.9 in IG (P = 0.027). Both nausea and vomiting had a significant correlation with reduced quality of life.

CONCLUSIONS & INFERENCES

Nausea and vomiting are significant symptoms of gastroparesis. Vomiting was greater in DG compared with IG, both in terms of severity score and number of vomiting episodes, whereas nausea severity was similar. Hours of nausea per day and episodes of vomiting per week appear to be useful parameters for assessing symptoms of gastroparesis. Nausea and vomiting have a significant impact on quality of life.

Prevalence of gastroparesis-related symptoms in an unselected cohort of patients with Type 1 diabetes

BACKGROUND

The prevalence of diabetic gastroparesis is not well defined because of discrepancy between objective measurements, i.e. gastric emptying time, and symptoms experienced by patients. Furthermore most studies have been performed on small selected cohorts.

OBJECTIVE

To determine the prevalence of clinical symptoms of diabetic gastroparesis in a large unselected cohort of out-patients with Type 1 diabetes.

METHODS

1028 patients with Type 1 diabetes attending a specialized diabetes clinic were mailed a validated questionnaire; "patient assessment of upper gastrointestinal disorders-symptom severity index", in which a subset of questions measures symptoms of gastroparesis (GCSI; Gastroparesis Cardinal Symptom Index). Response rate was 74.4% (n=765). All patients were classified according to presence or absence of late diabetic complications and clinical and paraclinical data were obtained.

RESULTS

A GCSI Total Score ≥1.90 signified definite symptoms of gastroparesis (n=102) and patient charts were investigated for concomitant illness and/or medication influencing gastric emptying. In 30 patients an alternative etiology was revealed, leaving 72 (9.8%) patients with symptoms related to diabetic gastroparesis. Only 8 patients were previously diagnosed. HbA(1c) levels were significantly higher in patients with diabetic gastroparesis (8.4±1.3 vs. 8.2±1.2 respectively, p=0.02). Furthermore, patients with diabetic gastroparesis had more retinopathy (p=0.006) and peripheral polyneuropathy (16.7% vs. 6.7%, p<0.001) and there was a trend for diabetic nephropathy being more common (p=0.08).

CONCLUSIONS

Symptoms of diabetic gastroparesis affect approximately 10% of patients with Type 1 diabetes in a specialized diabetes clinic and are associated with poor glycemic control and other late diabetic complications.

Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study

BACKGROUND

Botulinum toxin A has been used in children to treat spastic disorders and recently for GI conditions. Open-label studies in adults with gastroparesis have reported an improvement in symptoms and gastric emptying after endoscopic intrapyloric botulinum injections (IPBIs), although placebo-controlled trials have shown conflicting results. Only a single case report of IPBI is available in children.

OBJECTIVE

To determine the long-term clinical outcomes and predictive factors for IPBI response in children with gastroparesis refractory to medical therapy.

DESIGN

Retrospective review.

SETTING

Single tertiary care center.

PATIENTS

Children with refractory gastroparesis symptoms undergoing IPBIs.

INTERVENTIONS

IPBIs.

MAIN OUTCOME MEASUREMENTS

Clinical improvement and predictive factors for response.

RESULTS

A total of 70 injections were given to 47 patients (mean age 9.98 ± 6.5 years; 23 female patients) with follow-up in 45 patients. IPBI failed in 15 patients and was successful in 30 patients. The median duration of response to the first IPBI was 3.0 months (95% CI, 1.2-4.8). A total of 29 patients received a single IPBI, and 18 received multiple IPBIs. Older age and vomiting predicted response to initial IPBI, and male sex predicted response to repeat IPBI. Only 1 patient reported exacerbation of vomiting after IPBI resolving within a week.

LIMITATIONS

The open-label and retrospective nature of the study.

CONCLUSION

IPBI is safe and may be effective in the management of children with symptoms of gastroparesis. Subgroups identifying who responded to the first IPBI include older patients and those presenting with vomiting, whereas male patients responded better to repeat IPBIs.

Prevalence of hidden gastroparesis in the community: the gastroparesis "iceberg"

BACKGROUND/AIMS

The prevalence of diagnosed gastroparesis is 24.2/100,000 inhabitants, but a large group of people with gastroparesis-like symptoms have never had a gastric emptying (GE) test. Some of them may have undiagnosed gastroparesis. Our aim was to estimate the prevalence of hidden gastroparesis in the community.

METHODS

The study was conducted in 2 parts: (1) Patients referred for a scintigraphic GE test completed a validated questionnaire (Bowel Disease Questionnaire). Multiple linear regression models to predict 2 hours and 4 hours GE rates were developed. (2) A revised Bowel Disease Questionnaire was mailed to a random sample of 4,194 Olmsted County residents. GE rates were estimated with the models for each subject and delayed GE was considered when they were lower than normal values. Hidden gastroparesis was defined in community subjects with predicted delayed GE that had not been diagnosed with gastroparesis prior to the survey.

RESULTS

The regression models for GE rates were constructed using data from 450 patients. In addition to age and gender, the symptoms found significant were nausea/vomiting, early satiety, upper abdominal pain, bloating, loss of appetite and weight loss more than 7 pounds. 2,298 (55%) community subjects returned a questionnaire. Five subjects were excluded due to a prior diagnosis of gastroparesis. When models were applied to the community survey data, 42 (1.8%) subjects were estimated to have delayed GE.

CONCLUSIONS

Delayed GE was estimated to occur in 1.8% of community subjects. Since the prevalence of diagnosed gastroparesis is low (0.02%), many subjects with gastroparesis may remain undiagnosed.

Gastroparesis and Parkinson's disease: a systematic review

Some of the gastrointestinal (GI) symptoms commonly experienced by patients with Parkinson's disease (PD) have been attributed to gastroparesis; however, the precise prevalence and relevance of gastric emptying delay in PD is unclear. The definition of gastroparesis varies; currently the most widely accepted definition (from the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium) is the presence of appropriate symptoms (including nausea, retching, vomiting, stomach fullness, and inability to finish a meal) for ≥ 12 weeks, together with delayed gastric emptying on scintigraphy and the absence of any obstructive lesions on upper GI endoscopy. In PD patients, gastroparesis has the potential to affect nutrition and quality of life, as well as the absorption of PD medications, including L-dopa. This reduced absorption of L-dopa has implications for the control of the PD motor symptoms for which it is administered. We performed a systematic review of the literature on gastroparesis in PD with the aim of developing an evidence-based approach to its management. Based on this review, we conclude that while gastric emptying has been reported to be frequently delayed in PD, the existing data do not permit definitive conclusions concerning its true prevalence, relationship to the underlying disease process, relevance to PD management, or the optimal therapy of related GI symptoms. Further study of these important issues is, therefore, required.

Similarities and differences between diabetic and idiopathic gastroparesis

BACKGROUND & AIMS

Gastroparesis can be diabetic or idiopathic, yet little is known about differences in their presentation. We compared clinical characteristics, symptoms, and gastric emptying in patients with type 1 or type 2 diabetic (DG) or idiopathic (IG) gastroparesis.

METHODS

We analyzed data from 416 patients with gastroparesis who were enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Registry; 254 had IG (most were female and white), and 137 had DG (78 had type 1 and 59 had type 2). Registry data included detailed histories, physical examinations, results from gastric emptying scintigraphy, and responses to validated symptom questionnaires.

RESULTS

Patients with type 2 diabetes mellitus (DM) were an average of 13 years older at the onset of symptoms of gastroparesis and heavier than patients with IG. Patients with type 1 DM had more hospitalizations in the past year than patients with IG. Symptoms that prompted evaluation more often included vomiting for DG and abdominal pain for IG. Patients with DG had more severe retching and vomiting than those with IG, whereas patients with IG had more severe early satiety and postprandial fullness subscores. Compared with IG, gastric retention was greater in patients with type 1 DM. More than 50% of patients with type 1 DM had severe retention (>35% at 4 hours); they took prokinetic agents more frequently and were more likely to receive gastric electric stimulation.

CONCLUSIONS

There are similarities and differences in clinical characteristics of DG and IG. Gastroparesis is a heterogeneous disorder; its etiology affects symptoms and severity. Long-term studies are needed to determine whether the differences in symptoms and gastric emptying affect progression and treatment responses.

Comparison of clinical characteristics of patients with gastroesophageal reflux disease who failed proton pump inhibitor therapy versus those who fully responded

Background/Aims

Refractory gastroesophageal reflux disease (GERD) is very common, affecting up to 40% of the patients receiving proton pump inhibitor (PPI) therapy. However, there is not much information about the clinical characteristics of these patients. The aim of the study is to compare the clinical characteristics of PPI responders vs non-responders.

Methods

Consecutive GERD patients receiving PPI once or twice daily were evaluated by a questionnaire and a personal interview regarding their demographics, habits, clinical characteristics and endoscopic findings. The patients were divided into 3 groups: Patients who fully responded to PPI once daily (Group A, n = 111), patients who failed PPI once daily (Group B, n = 78) and patients who failed PPI twice daily (Group C, n = 56).

Results

A total of 245 patients (59.3% females, 52 ± 17.2 years of age) were included in this study. Cross-group differences (A vs B vs C) were detected for hiatal hernia (33% vs 51% vs 52%, P = 0.011); erosive esophagitis (19% vs 51% vs 30%, P < 0.0001); cough (24% vs 44% vs 43%, P = 0.007); sleep disturbances (19% vs 30% vs 38%, P = 0.033); chest symptoms (21% vs 35% vs 41%, P = 0.010); Helicobacter pylori status (25% vs 33% vs 48%, P < 0.0001), disease duration (1.6 ± 0.8 vs 1.9 ± 1.0 vs 2.0 ± 1.1 years, P = 0.007), performed lifestyle interventions (68.5% vs 46.7% vs 69.6%, P = 0.043) and compliance (84% vs 55% vs 46%, P < 0.0001).

Conclusions

PPI failure (either once or twice daily) appears to be significantly associated with atypical GERD symptoms, disease duration and severity, H. pylori status, obesity, performed lifestyle interventions and compliance as compared with PPI responders.

No evidence of impaired gastric emptying in early Huntington's Disease

Background: Several factors, such as dysphagia, an increased motor activity, increased metabolic rate and a hypermetabolic state have been discussed as contributing to weight loss even at the early stages of Huntington’s Disease (HD). Aim of this pilot study was to investigate gastric emptying as a possible reason for weight loss in HD.

Methods: 11 HD participants at early stages of the disease and matched controls were investigated by using the well-established and non-invasive 13C-octanoate breath test. The “Gastroparesis Cardinal Symptom Index” and the “Short-Form Leeds Dyspepsia Questionnaire” were used for clinical evaluation of gastroparesis or dyspepsia.

Results: When compared to standard values ​​given in literature and controls all HD patients had normal breath test results. There was no evidence of gastroparesis or dyspepsia. There was a correlation of breath test results with the cognitive and functional performance of HD participants.

Conclusion: According to our data, there is no evidence of impaired gastric emptying in early HD. We can not exclude that gastric emptying contributes to weight loss at more advanced stages of the disease.

Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement

BACKGROUND

Gastroparesis is a chronic digestive disorder with symptoms of nausea, vomiting, bloating, and abdominal pain resulting in a poor quality of life. Surgeons are increasingly asked to treat patients with gastroparesis as medical options have become limited due to safety concerns of many prokinetics. Surgical options include gastric stimulator implantation, sub-total gastrectomy, and pyloroplasty. We report our experience with minimally invasive pyloroplasty as sole surgical treatment for adult gastroparesis.

MATERIALS AND METHODS

A retrospective review of prospectively collected data of 28 patients who underwent minimally invasive pyloroplasty alone as treatment for gastroparesis from Jan 2007 to Sept 2010. Pre- and postoperative symptom severity score (SSS), gastric emptying scintigraphy (GES), and medication use were reviewed.

RESULTS

A laparoscopic Heineke-Mikulicz pyloroplasty was performed in 26 patients. A laparoscopic assisted, flexible trans-oral endoscopic circular stapled pyloroplasty was used in two patients. Prokinetic use was significantly reduced from 89% to 14% (p = <0.0001). The mean GES T1/2 decreased from 320 to 112 min (p = 0.001) and normalized in 71%. Significant improvements in the SSS were seen at 1 month for nausea (p = <0.0001), vomiting (p = <0.0001), bloating (p = 0.0023), abdominal pain (p = <0.0001), and gastroesophageal reflux disease (GERD) symptoms (p = 0.0143). Significant improvement persisted at 3 months for nausea (p = <0.0001), vomiting (p = <0.0001), bloating (p = 0.0004), abdominal pain (p = 0.0001) and GERD symptoms (p = 0.013). The average length of stay was 3.71 days. Overall, 83% of patients' indicated that they saw improvement at 1 month follow-up.

CONCLUSION

Minimally invasive pyloroplasty provides excellent outcomes for patients with gastroparesis and should be considered as a primary treatment along with diet and medications as it is effective and does not eliminate the option for additional surgical options in the future for refractory disease. With technological advancements, a totally endoscopic pyloroplasty may be a less invasive option.

Continuous glucose monitoring in gastroparesis

BACKGROUND

Delayed gastric emptying can alter glucose levels in diabetic patients; hyperglycemia can delay gastric emptying. Continuous glucose monitoring (CGM) may be useful to assess the relationship between gastric emptying and blood glucose levels.

AIMS

The aims of this study were to compare the postprandial blood glucose profile of patients with type 2 diabetes mellitus (T2DM) with and without gastroparesis, normal subjects, and patients with idiopathic gastroparesis (IG), and also to determine the effect of different meal compositions on glucose regulation in T2DM and normals.

METHODS

Seven patients with IG, seven T2DM with gastroparesis, ten non-gastroparetic T2DM, and ten normal subjects underwent CGM during a low fat (Eggbeaters) meal. Glucose profiles were also studied in T2DM and normal subjects after high fat, high fiber, spicy, and Ensure liquid nutrient meals.

RESULTS

After the Eggbeaters meal, the glucose profile of IGs and normals were similar. Diabetic patients with gastroparesis had similar peak postprandial blood glucose to nongastroparetic diabetics (231 ± 26 vs. 232 ± 18 mg/dl), but had a higher postprandial blood glucose at the end of the 4 h study (187 ± 26 mg/dl vs. 97 ± 10; P = 0.01). In contrast to normals, non-gastroparetic diabetics had higher mean postprandial blood sugar after the Eggbeaters meal (173 ± 5 mg/dl) compared to high fat (157 ± 3; P = 0.002), spicy (133 ± 2; P < 0.001) and Ensure meals (152 ± 1; P < 0.001).

CONCLUSIONS

Blood glucose monitoring provides insight to the presence of gastroparesis in diabetic patients: diabetic gastroparetics had prolonged postprandial hyperglycemic profile as compared to non-gastroparetic diabetics. Of the meals tested, the low fat (Eggbeaters) meal was associated with the highest mean postprandial glucose in diabetics.

Obesity and symptoms suggestive of gastroparesis in patients with type 2 diabetes and neuropathy

BACKGROUND

Associated with neuropathy, symptoms suggestive of gastroparesis are common in patients with type 2 diabetes mellitus (T2DM) and include nausea, vomiting, bloating and early satiety. Gastric motor abnormalities have been reported in obese patients, and obesity is associated with T2DM. An association between obesity and gastroparesis symptoms in diabetic patients with neuropathy has not been investigated.

METHODS

In this nested case-control study, 161 patients with neuropathy were identified from within a cross-sectional survey of 380 T2DM patients. Of these, 134 (83.2%, "cases") had at least one cardinal symptom suggestive of gastroparesis. The remaining symptom-free subjects served as controls. Logistic and general linear modeling was used to assess associations between obesity and the presence and number of symptoms.

RESULTS

Subjects were 66.6±10 years of age. Cases were significantly more likely than controls to be obese (89% vs. 77%, P=.04), female (55.6% vs. 33.3%) and hypertensive (90.2% vs. 63%, P=.001) and to report adherence to diet (87.4% vs. 66.7%, P=.007). In a logistic regression model including sex, hypertension, antiaggregant therapy, adherence to diet therapy and an obesity-by-sex interaction term, obesity emerged as a significant independent predictor of any cardinal symptom suggestive of gastroparesis (odds ratio 9.86, 95% confidence interval 1.4-69.2, P=.02). Obesity was also identified as a significant independent predictor of number of cardinal symptoms suggestive of gastroparesis in the general linear model. Obese subjects reported significantly more early satiety (61.5% vs. 35.2%, P=.001), fullness (63.7% vs. 40.8%, P=.004), bloating (70.3% vs. 49.3%, P=.006) and abdominal distention (71.4 vs. 50.7%, P=.007) than nonobese subjects. Further, obese subjects reported more cardinal symptoms suggestive of gastroparesis symptoms (4.2±2.4 vs. 3.1±2.5, P=.01).

CONCLUSIONS

Obesity emerged as a significant independent predictor of cardinal symptoms suggestive of gastroparesis in patients with T2DM and neuropathy. This finding suggests that mechanisms in addition to neuropathy play a role in the generation of symptoms suggestive of gastroparesis in this patient population.

Bloating in gastroparesis: severity, impact, and associated factors

OBJECTIVES

Bloating is commonly reported in gastroparesis, but its prevalence, impact, and associated factors are uninvestigated. We aimed to quantify the prevalence of bloating in gastroparesis and relate its severity to clinical factors and quality of life.

METHODS

Survey, examination, and scintigraphy data were compared in 335 gastroparesis patients from 6 centers of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Gastroparesis Clinical Research Consortium. Bloating severity was stratified using Gastroparesis Cardinal Symptom Index (GCSI) bloating subscale scores.

RESULTS

Bloating severity of at least mild (GCSI ≥2) and severe (GCSI ≥4) grades were reported by 76 and 41% of patients, respectively. Bloating severity related to female gender (P<0.0001) and overweight status (P=0.04) on regression analysis and correlated with intensity of nausea, postprandial fullness, visible distention, abdominal pain, and altered bowel function (P<0.05). Disease etiology, smoking status, and gastric emptying did not relate to bloating subset (P>0.05). Disease-specific quality of life and general measures of well-being were progressively impaired with increasing bloating severity (P=0.01). Probiotic use (P=0.03) and use of antidepressants with significant norepinephrine reuptake inhibitor activity (P=0.045) use related to bloating severity; antiemetic use trended higher with worsening bloating (P=0.06).

CONCLUSIONS

Bloating is prevalent in gastroparesis and is severe in many individuals. Bloating severity relates to female gender, body weight, and intensity of other symptoms. The symptom impairs quality of life but is not influenced by gastric emptying rates. Antiemetics, probiotics, and antidepressants with significant norepinephrine reuptake inhibitor activity may affect reports of bloating. These findings provide insight into this underappreciated symptom of gastroparesis.

Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis

BACKGROUND & AIMS

Gastroparesis can lead to food aversion, poor oral intake, and subsequent malnutrition. We characterized dietary intake and nutritional deficiencies in patients with diabetic and idiopathic gastroparesis.

METHODS

Patients with gastroparesis on oral intake (N = 305) were enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Registry and completed diet questionnaires at 7 centers. Medical history, gastroparesis symptoms, answers to the Block Food Frequency Questionnaire, and gastric emptying scintigraphy results were analyzed.

RESULTS

Caloric intake averaged 1168 ± 801 kcal/day, amounting to 58% ± 39% of daily total energy requirements (TER). A total of 194 patients (64%) reported caloric-deficient diets, defined as <60% of estimated TER. Only 5 patients (2%) followed a diet suggested for patients with gastroparesis. Deficiencies were present in several vitamins and minerals; patients with idiopathic disorders were more likely to have diets with estimated deficiencies in vitamins A, B(6), C, K, iron, potassium, and zinc than diabetic patients. Only one-third of patients were taking multivitamin supplements. More severe symptoms (bloating and constipation) were characteristic of patients who reported an energy-deficient diet. Overall, 32% of patients had nutritional consultation after the onset of gastroparesis; consultation was more likely among patients with longer duration of symptoms and more hospitalizations and patients with diabetes. Multivariable logistic regression analysis indicated that nutritional consultation increased the chances that daily TER were met (odds ratio, 1.51; P = .08).

CONCLUSIONS

Many patients with gastroparesis have diets deficient in calories, vitamins, and minerals. Nutritional consultation is obtained infrequently but is suggested for dietary therapy and to address nutritional deficiencies.

Gastroparesis: pathogenesis, diagnosis and management

Gastroparesis is a prevalent condition that produces symptoms of delayed gastric emptying in the absence of physical blockage. The most common etiologies of gastroparesis are idiopathic, diabetic, and postsurgical disease, although some cases stem from autoimmune, paraneoplastic, neurologic or other conditions. Histologic examination of gastric tissues from patients with severe gastroparesis reveals heterogeneous and inconsistent defects in the morphology of enteric neurons, smooth muscle and interstitial cells of Cajal, and increased levels of inflammatory cells. Diagnosis is most commonly made by gastric emptying scintigraphy; however, wireless motility capsules and nonradioactive isotope breath tests have also been validated. A range of treatments have been used for gastroparesis including dietary modifications and nutritional supplements, gastric motor stimulatory or antiemetic medications, endoscopic or surgical procedures, and psychological interventions. Most treatments have not been subjected to controlled testing in patients with gastroparesis. The natural history of this condition is poorly understood. Active ongoing research is providing important insights into the pathogenesis, diagnosis, treatment and outcomes of this disease.

Characteristics of patients with chronic unexplained nausea and vomiting and normal gastric emptying

BACKGROUND & AIMS

Chronic nausea and vomiting with normal gastric emptying is a poorly understood syndrome; we analyzed its characteristics.

METHODS

We collected and analyzed data from 425 patients with chronic nausea and vomiting, enrolled at 6 centers by the Gastroparesis Clinical Research Consortium in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Registry.

RESULTS

Among the patients, 319 (75%) had delayed emptying, defined by the results of a standardized, low-fat meal, and 106 had normal gastric emptying. Patients with or without delayed emptying did not differ in age, sex, or race, although those with normal gastric emptying were less likely to be diabetic. Symptom severity indexes were similar between groups for nausea, retching, vomiting, stomach fullness, inability to complete a meal, feeling excessively full after meals, loss of appetite, bloating, and visibly larger stomach. There were no differences in health care utilization, quality of life indexes, depression, or trait anxiety scores. However, state anxiety scores were slightly higher among patients with delayed gastric emptying. Total gastroparesis cardinal symptom index scores were not correlated with gastric retention after 2 or 4 hours in either group. Patients with the syndrome were not adequately captured by the stand-alone criteria for the Rome III diagnoses of chronic idiopathic nausea and functional vomiting. With rare exceptions, the diagnosis remained stable after a 48-week follow-up period.

CONCLUSIONS

Patients with nausea and vomiting with normal gastric emptying represent a significant medical problem and are, for the most part, indistinguishable from those with gastroparesis. This syndrome is not categorized in the medical literature--it might be a separate clinical entity.

Percutaneous endoscopically assisted transenteric full-thickness gastric biopsy: initial experience in humans

BACKGROUND

GI neuromuscular diseases (GINMD) can cause severe dysmotility and symptoms. Full-thickness biopsy specimens may help diagnose these disorders histologically.

OBJECTIVE

To assess a novel percutaneous endoscopically assisted transenteric (PEATE) biopsy method for obtaining full-thickness gastric tissue in patients with suspected GINMD.

DESIGN

Prospective proof-of-concept case series.

SETTING

Tertiary care gastroenterology unit.

PATIENTS

Ten patients (8 women, mean [standard deviation] age 43 [10] years) with gastroparesis-like symptoms (mean [standard deviation] gastroparesis cardinal symptom index 3.28 [1.46] out of 5) and/or clinical findings suggestive of a gastric GINMD.

INTERVENTIONS

All patients underwent PEATE biopsy during standard gastroscopy as an outpatient procedure. Tissue was stained for histology and immunohistochemistry of gut wall elements. Interstitial cells of Cajal (ICC) counts were compared with archived normal gastric tissue from control gastrectomies.

MAIN OUTCOME MEASUREMENTS

Biopsy success, complications, histopathological findings according to the London Classification of GINMD.

RESULTS

Full-thickness antral tissue suitable for analysis was obtained in 9 in 10 patients (90%). PEATE biopsy was well tolerated by all patients without complications. Histology suggested GINMD in 4 of 9 cases (44%), with possible degenerative leiomyopathy in 2, probable inflammatory leiomyopathy in 1, and abnormal ICC networks (>50% reduction in ICC counts) in 1 patient.

LIMITATIONS

PEATE biopsy specimen size is smaller than a standard laparoscopic full-thickness biopsy.

CONCLUSIONS

PEATE full-thickness gastric biopsy is a simple and safe method of assessing histopathological abnormalities in gastric GINMD without the need for laparoscopy or general anesthesia.

The effects of LY2189265, a long-acting glucagon-like peptide-1 analogue, in a randomized, placebo-controlled, double-blind study of overweight/obese patients with type 2 diabetes: the EGO study

AIM

To evaluate the efficacy and tolerability of once-weekly LY2189265 (LY), a novel glucagon-like peptide-1 (GLP-1) IgG4-Fc fusion protein, in patients with type 2 diabetes failing oral antihyperglycaemic medications (OAMs).

METHODS

Placebo-controlled, double-blind study in 262 patients (mean age 57 ± 12 years; BMI 33.9 ± 4.1 kg/m(2); and glycosylated haemoglobin A1c (A1c) 8.24 ± 0.93%) receiving two OAMs. Patients were randomized to once-weekly subcutaneous injections of placebo or LY 0.5 mg for 4 weeks, then 1.0 mg for 12 weeks (LY 0.5/1.0); 1.0 mg for 16 weeks (LY 1.0/1.0); or 1.0 mg for 4 weeks, then 2.0 mg for 12 weeks (LY 1.0/2.0).

RESULTS

At week 16, A1c changes (least-squares mean ± standard error) were -0.24 ± 0.12, -1.38 ± 0.12, -1.32 ± 0.12 and -1.59 ± 0.12%, in the placebo, LY 0.5/1.0, LY 1.0/1.0 and LY 1.0/2.0 arms, respectively (all p < 0.001 vs. placebo). Both fasting (p < 0.001) and postprandial (p < 0.05) blood glucose decreased significantly compared to placebo at all LY doses. Weight loss was dose dependent and ranged from -1.34 ± 0.39 to -2.55 ± 0.40 kg at 16 weeks (all p < 0.05 vs. placebo). At the highest LY dosage, the most common adverse events were nausea (13.8%), diarrhoea (13.8%) and abdominal distension (13.8%). Hypoglycaemia was uncommon overall (≤0.8 episodes/patient/30 days) but more common with LY than placebo through the initial 4 weeks (p < 0.05). No differences in cardiovascular events or blood pressure were shown between treatments.

CONCLUSIONS

LY2189265, given to overweight/obese patients with type 2 diabetes for 16 weeks in combination with OAMs, was relatively well tolerated and significantly reduced A1c, blood glucose and body weight.

Gastric emptying of solids and liquids for evaluation for gastroparesis

BACKGROUND

Gastric emptying scintigraphy (GES) of solids is typically used to evaluate for gastroparesis.

AIMS

The purpose of this study was to determine the value of simultaneously measuring gastric emptying of liquids and solids for assessing patients for delayed gastric emptying.

METHODS

A total of 596 patients at our institution from September 2007 to January 2010 underwent GES with assessment of both solid and liquid gastric emptying. An EggBeaters® with jam sandwich meal radiolabeled with Tc-99 m was used for solid GES and water radiolabeled with In-111 for liquid GES.

RESULTS

Inclusion criteria (no medications affecting gastric motility in 48 h prior to test; no prior gastric surgery) was met by 449 patients. Liquid gastric emptying was significantly correlated to solid gastric emptying: 30 min (r=0.652, P<0.001), 60 min (r=0.624, P<0.001) and 120 min (r=0.766, P<0.001). Interestingly, 60 patients, of which 57 were nondiabetic, had normal solid GES but delayed liquid emptying and represented 26% of the 228 patients with normal solid GES. Gastric retention of solids was mildly correlated with nausea, vomiting, loss of appetite, early satiety and feeling excessively full after meals. Gastric emptying of liquids was associated with early satiety and loss of appetite.

CONCLUSIONS

Gastric emptying of liquids correlates well with gastric emptying of solids. When evaluating patients for gastroparesis, assessment of gastric emptying of liquids in addition to solids may help identify additional patients with delayed gastric emptying, particularly non-diabetic patients where 26% with normal solid emptying may have delayed emptying of liquids. Symptoms of gastroparesis, however, are primarily associated with delayed gastric emptying of solids.

Gastroparesis: approach, diagnostic evaluation, and management

Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels--autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

Randomised clinical trial: ghrelin agonist TZP-101 relieves gastroparesis associated with severe nausea and vomiting--randomised clinical study subset data

BACKGROUND

Limited therapeutic options exist for severe gastroparesis, where severe nausea and vomiting can lead to weight loss, dehydration and malnutrition due to inadequate caloric and fluid intake. TZP-101 (ulimorelin) is a ghrelin receptor agonist that accelerates gastric emptying and improves upper gastrointestinal symptoms in diabetic patients with gastroparesis.

AIM

To assess effects of TZP-101 in diabetic gastroparesis patients with severe nausea/vomiting and baseline severity scores of ≥3.5 (range: 0-5) on the Gastroparesis Cardinal Symptom Index (GCSI) Nausea/Vomiting subscale.

METHODS

Patients were hospitalised and received four single daily 30-min infusions of one of six TZP-101 doses (range 20-600 μg/kg) or placebo. Efficacy was assessed by symptom improvement.

RESULTS

At baseline, 23 patients had a mean severity score for GCSI Nausea/Vomiting of 4.45±0.44. Statistically significant improvements over placebo occurred in the 80 μg/kg group for end of treatment changes from baseline in GCSI Nausea/Vomiting subscale (reduction in score of -3.82±0.76, P=0.011) and the GCSI Total score (-3.14±0.78, P=0.016) and were maintained at the 30-day follow-up assessment (-2.02±1.63, P=0.073 and -1.99±1.33, P=0.032 respectively). The proportion of days with vomiting was reduced significantly (P=0.05) in the 80 μg/kg group (mean of 1.2 days of vomiting for four treatment days) compared with placebo (mean of 3.2 days of vomiting across 4 treatment days).

CONCLUSIONS

TZP-101 substantially reduced the frequency and severity of nausea and vomiting as well as overall gastroparesis symptoms. The results are consistent with gastrointestinal motility effects of TZP-101, supporting further investigation of TZP-101 in the management of severe gastroparesis.

Clinical features of idiopathic gastroparesis vary with sex, body mass, symptom onset, delay in gastric emptying, and gastroparesis severity

BACKGROUND & AIMS

Idiopathic gastroparesis (IG) is a common but poorly understood condition with significant morbidity. We studied characteristics of patients with IG enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium Registry.

METHODS

Data from medical histories, symptom questionnaires, and 4-hour gastric emptying scintigraphy studies were obtained from patients with IG.

RESULTS

The mean age of 243 patients with IG studied was 41 years; 88% were female, 46% were overweight, 50% had acute onset of symptoms, and 19% reported an initial infectious prodrome. Severe delay in gastric emptying (>35% retention at 4 hours) was present in 28% of patients. Predominant presenting symptoms were nausea (34%), vomiting (19%), an abdominal pain (23%). Women had more severe nausea, satiety, constipation, and overall gastroparesis symptoms. Patients who experienced acute-onset IG had worse nausea than those with insidious onset. Overweight patients had more bloating and gastric retention at 2 hours but less severe loss of appetite. Patients with severely delayed gastric emptying had worse vomiting and more severe loss of appetite and overall gastroparesis symptoms. Severe anxiety and depression were present in 36% and 18%, respectively. A total of 86% met criteria for functional dyspepsia, primarily postprandial distress syndrome.

CONCLUSIONS

IG is a disorder that primarily affects young women, beginning acutely in 50% of cases; unexpectedly, many patients are overweight. Severe delay in gastric emptying was associated with more severe symptoms of vomiting and loss of appetite. IG is a diverse syndrome that varies by sex, body mass, symptom onset, and delay in gastric emptying.

Management of diabetic gastroparesis

Symptoms suggestive of gastroparesis occur in 5% to 12% of patients with diabetes. Such a complication can affect both prognosis and management of the diabetes; therefore, practicing clinicians are challenged by the complex management of such cases. Gastroparesis is a disorder characterized by a delay in gastric emptying after a meal in the absence of a mechanical gastric outlet obstruction. This article is an evidence-based overview of current management strategies for diabetic gastroparesis. The cardinal symptoms of diabetic gastroparesis are nausea and vomiting. Gastroesophageal scintiscanning at 15-minute intervals for 4 hours after food intake is considered the gold standard for measuring gastric emptying. Retention of more than 10% of the meal after 4 hours is considered an abnormal result, for which a multidisciplinary management approach is required. Treatment should be tailored according to the severity of gastroparesis, and 25% to 68% of symptoms are controlled by prokinetic agents. Commonly prescribed prokinetics include metoclopramide, domperidone, and erythromycin. In addition, gastric electrical stimulation has been shown to improve symptoms, reduce hospitalizations, reduce the need for nutritional support, and improve quality of life in several open-label studies.

Psychological dysfunction is associated with symptom severity but not disease etiology or degree of gastric retention in patients with gastroparesis

OBJECTIVES

Gastroparesis patients may have associated psychological distress. This study aimed to measure depression and anxiety in gastroparesis in relation to disease severity, etiology, and gastric retention.

METHODS

Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) scores for state (Y1) and trait (Y2) anxiety were obtained from 299 gastroparesis patients from 6 centers of the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium. Severity was investigator graded as grades 1, 2, or 3 and patient reported by Gastroparesis Cardinal Symptom Index (GCSI) scores. Antiemetic/prokinetic medication use, anxiolytic and antidepressant medication use, supplemental feedings, and hospitalizations were recorded. BDI, Y1, and Y2 scores were compared in diabetic vs. idiopathic etiologies and mild (≤20%) vs. moderate (>20-35%) vs. severe (>35-50%) vs. very severe (>50%) gastric retention at 4 h.

RESULTS

BDI, Y1, and Y2 scores were greater with increasing degrees of investigator-rated gastroparesis severity (P<0.05). BDI, Y1, and Y2 scores were higher for GCSI >3.1 vs. ≤3.1 (P<0.05). Antiemetic and prokinetic use and ≥6 hospitalizations/year were more common with BDI ≥20 vs. <20 (P<0.05). Anxiolytic use was more common with Y1≥46; antidepressant use and ≥6 hospitalizations/year were more common with Y2≥44 (P<0.05). BDI, Y1, and Y2 scores were not different in diabetic and idiopathic gastroparesis and did not relate to degree of gastric retention. On logistic regression, GCSI >3.1 was associated with BDI ≥20 and Y1≥46; antiemetic/prokinetic use was associated with BDI≥20; anxiolytic use was associated with Y1≥46; and antidepressant use was associated with Y2≥44.

CONCLUSIONS

Higher depression and anxiety scores are associated with gastroparesis severity on investigator- and patient-reported assessments. Psychological dysfunction does not vary by etiology or degree of gastric retention. Psychological features should be considered in managing gastroparesis.

Preoperative predictors of significant symptomatic response after 1 year of gastric electrical stimulation for gastroparesis

BACKGROUND

In cases of gastroparesis where significant symptoms fail to respond to standard medical therapy, gastric electrical stimulation (GES) may be of benefit. Unfortunately, not all patients improve with this therapy. Reliable preoperative predictors of symptomatic response to GES may allow clinicians to offer this expensive and invasive treatment to only those patients most likely to benefit.

METHODS

Therapy was initiated in 15 patients more than 12 months prior to this retrospective review of our prospectively maintained data. All patients completed a Total Symptom Score (TSS) survey at every encounter as well as the SF-36 quality-of-life instrument prior to surgery. A failure of GES therapy was considered to have occurred when after 1 year of treatment, preoperative TSS had not decreased by at least 20%.

RESULTS

Four patients (4 idiopathic) failed to improve more than 20% on multiple assessments after a year of therapy. All diabetic patients experienced a durable symptomatic improvement with GES. Review of individual items of the TSS revealed that nonresponders experienced less severe vomiting preoperatively.

CONCLUSIONS

Diabetic gastroparesis patients respond best to GES. Responders tend to have more severe vomiting preoperatively. Patients with idiopathic gastroparesis who do not experience severe vomiting should be cautioned about a potentially higher rate of poor response to GES and may be better served with alternative treatments.

Abdominal pain is a frequent symptom of gastroparesis

BACKGROUND & AIMS

Although the most commonly recognized symptoms of gastroparesis (GP) are nausea and vomiting, patients also report abdominal pain. We aimed to define the prevalence, severity, and quality of abdominal pain in GP and to correlate abdominal pain with gastric emptying (GE) and quality of life.

METHODS

Patients presumed to have GP underwent 4-hour GE scintigraphy and upper endoscopy examinations and completed the following: patient assessments of gastrointestinal symptoms (Patient Assessment of Upper Gastrointestinal Symptom Severity Index), abdominal pain questionnaires (Short-Form of the McGill Pain Questionnaire), and quality-of-life questionnaires.

RESULTS

The study group consisted of 68 patients (58 female; 10 male) with delayed GE (18 diabetic gastroparesis [DG] and 50 idiopathic gastroparesis [IG]). Abdominal pain was present in 90% of patients (89% DG, 90% IG) and nausea was present in 96% (100% DG, 94% IG). Abdominal pain was epigastric in 43% and umbilical in 13%. Pain occurred daily in 43% and was constant in 38%. Pain often was induced by eating (72%), was nocturnal (74%), and interfered with sleep (66%). Severity ranking of symptoms based on the Patient Assessment of Upper Gastrointestinal Symptom Severity Index was as follows: abdominal fullness (3.8 +/- 0.2), bloating (3.6 +/- 0.2), nausea (3.6 +/- 0.2), upper abdominal discomfort (3.3 +/- 0.2), upper abdominal pain (3.0 +/- 0.2), and vomiting (2.2 +/- 0.2). Abdominal pain severity did not correlate with GE, but had moderate correlation with quality of life.

CONCLUSIONS

Abdominal pain is a frequent symptom in patients with GP, comparable with nausea and vomiting. Abdominal pain correlates with impaired quality of life but not with GE.

Assessment of symptoms during gastric emptying scintigraphy to correlate symptoms to delayed gastric emptying

BACKGROUND

Symptoms of gastroparesis based on patient recall correlate poorly with gastric emptying. The aim of this study is to determine if symptoms recorded during gastric emptying scintigraphy (GES) correlate with gastric emptying and with symptoms based on patient recall.

METHODS

Patients undergoing GES completed the Patient Assessment of GI Symptoms (PAGI-SYM) assessing symptoms over the prior 2 weeks and a questionnaire for which patients graded six symptoms during GES. A Symptom Severity Index (SSI) represented the mean of six symptoms at each time point.

KEY RESULTS

A total of 560 patients underwent GES for clinical evaluation of symptoms. Of 388 patients included in the study: 232 patients had normal GES (NGES), 156 delayed GES (DGES), and 11 rapid GES (RGES). Symptom severity index increased pre to postprandial for each group: NGES: 0.51 +/- 0.07 to 0.92 +/- 0.03, DGES: 0.60 +/- 0.09 to 1.13 +/- 0.05, and RGES: 0.56 +/- 0.12 to 0.79 +/- 0.13. Delayed gastric emptying scintigraphy patients had a higher postprandial SSI than NGES patients (1.13 +/- 0.05 vs 0.92 +/- 0.03, P < 0.05). Postprandial symptoms of stomach fullness (1.9 +/- 0.12 vs 1.5 +/- 0.09; P = 0.011), bloating (1.4 +/- 0.11 vs 1.1 +/- 0.09; P = 0.033), and abdominal pain (1.1 +/- 0.08 vs 0.7 +/- 0.12; P = 0.012) were higher in DGES than NGES. Symptom severity based on PAGI-SYM for 2 weeks prior to GES correlated with symptoms during the test for nausea (NGES, r = 0.61; DGES, r = 0.70), stomach fullness (NGES, r = 0.47; DGES, r = 0.60), and bloating (NGES, r = 0.62, DGES, r = 0.66).

CONCLUSIONS & INFERENCES

Stomach fullness, bloating, and abdominal pain recorded during GES were higher in patients with delayed gastric emptying than in patients with normal gastric emptying. Symptoms recorded during GES correlated with those during daily life by patient recall.

Pharmacokinetic profile of immediate-release omeprazole in patients with gastro-oesophageal reflux associated with gastroparesis

BACKGROUND

Immediate-release omeprazole has a more rapid absorption compared with delayed-release omeprazole in asymptomatic volunteers. However, effects of delayed gastric emptying on omeprazole absorption remain unknown.

AIM

To compare pharmacokinetics between immediate and delayed-release omeprazole in patients with GERD associated with gastroparesis.

METHODS

Open-label, randomized, cross-over study was performed. Antireflux and prokinetic medications were discontinued. Subjects were randomized into: (i) Immediate-release omeprazole 40 mg suspension o.m. for 7 days, wash-out for 10-14 days, followed by delayed-release omeprazole 40 mg capsule o.m. for 7 days, or (ii) the same schedule in reverse order. On day 7, omeprazole concentrations were obtained before and up to 5 h after taking the study drug. Patient Assessment of GI Disorders-Symptom Severity Index was obtained.

RESULTS

A total of 12 women (mean age 51 years) completed the protocol. Time to maximal omeprazole concentration was significantly shorter for omeprazole. Maximal concentration was significantly greater for omeprazole, but total area under concentration-time curves was similar. Pharmacokinetic profile was less variable for immediate compared with delayed-release omeprazole.

CONCLUSIONS

Immediate-release omeprazole was associated with a more rapid absorption and less variable pharmacokinetic profile compared with delayed-release omeprazole in reflux patients associated with gastroparesis.

Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting

BACKGROUND

Despite the relatively high prevalence of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders.

PURPOSE

This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.

Different faces of gastroparesis

AIM: To test the hypothesis that pain and affect rather than impaired emptying determine symptom severity in patients with gastroparesis.

METHODS: Adult patients with documented gastroparesis were enrolled prospectively in a single center and asked to complete the Gastroparesis Cardinal Symptom Index (GCSI), Hospital Anxiety and Depression Scale (HADS), the Short Form 12 (SF-12) as quality of life index, rate pain severity and answer 10 open-ended questions.

RESULTS: A total of 55 patients (44 women) participated. Idiopathic (n = 29) or diabetic (n = 11) gastroparesis and connective tissue disease (n = 8) were the most common underlying causes. Antiemetics (n = 30) and prokinetics (n = 32) were most often prescribed. Seventeen patients used opioids on a daily basis. Nausea and/or vomiting (n = 28), pain (n = 24) and bloating (n = 14) were most commonly listed as dominant symptoms. Patients subjectively attributed symptom improvement to nutritional and dietary therapy (n = 11), prokinetics (n = 11), antiemetics (n = 10) or analgesic agents (n = 3). In univariate analyses, the physical subscore of the SF-12 and HADS, but not gastric emptying delay or symptom duration significantly correlated with disease severity as measured by the GCSI. In multivariate analyses, the combination of vomiting, bloating and depression best predicted the overall impact on quality of life.

CONCLUSION: The study confirms the importance of pain and affect in gastroparesis, which requires novel approaches to improve more effectively the quality of life in patients with this disorder.

Development and content validity of a gastroparesis cardinal symptom index daily diary

BACKGROUND

The Gastroparesis Cardinal Symptom Index (GCSI) is a patient-reported outcome for gastroparesis using a two-week recall period. To minimize potential patient recall effects, a daily diary version of the GCSI (GCSI-DD) was developed.

AIMS

To evaluate the content validity of GCSI-DD for the symptoms in patients with documented gastroparesis, to capture symptom variability over time and to compare responses of this GCSI-DD to the original GCSI.

METHODS

In gastroparesis adults with delayed gastric emptying, cognitive debriefing interviews were conducted to elicit their perspective on relevant symptoms of gastroparesis and relevant recall periods and to evaluate patient understanding of GCSI-DD. Patients completed the GCSI-DD daily over a 2-week period and completed the GCSI at baseline and the 2-week follow-up visit.

RESULTS

Twelve gastroparesis patients, of whom five were diabetic and nine women, reported nausea (100%), vomiting (100%), stomach fullness (75%), bloating (58%) and loss of appetite (50%) were important symptoms. All patients understood diary instructions and item content and reported that the diary captured their gastroparesis symptom experience; 83% considered response scales adequate. There was significant daily variability in GCSI-DD scores. Mean GCSI-DD subscale and total scores over 2 weeks correlated strongly (all r > 0.90) with GCSI scores at 2-week follow-up.

CONCLUSIONS

The GCSI-DD includes symptoms relevant to patients with gastroparesis, captures daily variability of those symptoms and has psychometric properties consistent with a good patient-reported outcome endpoint for gastroparesis clinical trials.

Gastroparesis and gastroparesis-like syndrome: response to therapy and its predictors

PURPOSE

The natural history and outcome of patients with gastroparesis is not well known. The aim of this study was to identify the clinical or pathophysiological characteristics, if any, that may be helpful in predicting therapeutic response in this condition.

METHODS

This is a retrospective study of a cohort of patients who presented to a tertiary referral center with symptoms suggestive of gastroparesis. All patients were evaluated by scintigraphic measurement of gastric emptying and symptoms were scored using a modification of the Gastroparesis Cardinal Symptom Index (GCSI). Treatment generally included conservative measures such as antiemetics, prokinetics, tricyclic antidepressants, and analgesics as well as various more invasive interventions in selected patients. Response to treatment was defined as a change in the overall GCSI score of two-thirds or more as compared with baseline.

RESULTS

Out of a total of 93 patients, 69 patients met the eligibility criteria. Of these, 29 patients had diabetes mellitus and 40 patients had gastroparesis of nondiabetic etiology. Out of 69 patients, 49 were responders (71%) and 20 were nonresponders (29%). The cause (diabetic versus nondiabetic) of gastroparesis or the presence of delayed emptying did not correlate with response. However, the severity of stomach distension, bloating subscale score, and the global GCSI score at baseline presentation were predictive of response by multivariate analysis.

CONCLUSION

Higher global GCSI score, bloating subscale score, and severity of stomach distension at baseline presentation correlated with an unfavorable response in gastroparetic patients. On the other hand, neither the etiology of gastroparesis nor associated delay in gastric emptying appeared to be important in the clinical response. Patients with symptoms of typical gastroparesis but without delays in gastric emptying may have a distinct syndrome with a greater proportion of males than classical gastroparesis.

Pathophysiology and management of gastroparesis

Gastroparesis is characterized by upper gastrointestinal symptoms associated with delayed gastric emptying, without mechanical obstruction. However, symptoms do not correlate well with the magnitude of delay in gastric emptying. Diabetes mellitus and surgery are the most common causes, although more than 30% of cases are idiopathic. Coordination of insulin action with nutrient delivery is important in diabetics, as postprandial blood glucose levels and gastric emptying are interdependent, and gastroparesis probably represents a major cause of poor glycemic control. Scintigraphy is the gold standard for measuring gastric emptying. Current treatment mainly involves the use of prokinetic drugs. Pyloric botulinum toxin injection and gastric electrical stimulation require more evidence from controlled studies before their use can be recommended. Surgical options remain inadequately studied.

The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006

BACKGROUND & AIMS

The epidemiology of gastroparesis is unknown. We aimed to determine the incidence, prevalence, and outcome of gastroparesis in the community.

METHODS

Using the Rochester Epidemiology Project, a medical records linkage system in Olmsted County, Minnesota, we identified county residents with potential gastroparesis. The complete medical records were reviewed by a gastroenterologist. Three diagnostic definitions were used: (1) definite gastroparesis, delayed gastric emptying by standard scintigraphy and typical symptoms for more than 3 months; (2) probable gastroparesis, typical symptoms and food retention on endoscopy or upper gastrointestinal study; (3) possible gastroparesis, typical symptoms alone or delayed gastric emptying by scintigraphy without gastrointestinal symptoms. Poisson regression was used to assess the association of incidence rates with age, sex, and calendar period.

RESULTS

Among 3604 potential cases of gastroparesis, 83 met diagnostic criteria for definite gastroparesis, 127 definite plus probable gastroparesis, and 222 any of the 3 definitions of gastroparesis. The age-adjusted (to the 2000 US white population) incidence per 100,000 person-years of definite gastroparesis for the years 1996-2006 was 2.4 (95% confidence interval [CI], 1.2-3.8) for men and 9.8 (95% CI, 7.5-12.1) for women. The age-adjusted prevalence of definite gastroparesis per 100,000 persons on January 1, 2007, was 9.6 (95% CI, 1.8-17.4) for men and 37.8 (95% CI, 23.3-52.4) for women. Overall survival was significantly lower than the age- and sex-specific expected survival computed from the Minnesota white population (P<.05).

CONCLUSIONS

Gastroparesis is an uncommon condition in the community but is associated with a poor outcome.

A single-blinded, randomized pilot study evaluating effects of electroacupuncture in diabetic patients with symptoms suggestive of gastroparesis

BACKGROUND AND OBJECTIVES

The current pharmacological management of diabetic gastroparesis remains difficult. Acupuncture has been widely used for gastrointestinal symptoms. The aim of this study was to investigate the effects of electroacupuncture (EA) on solid gastric emptying time, serum gastrin, motilin, pancreatic polypeptide (PP), fasting and postprandial blood glucose, and symptoms in patients with diabetic gastroparesis.

INTERVENTIONS

EA at the Zusanli (ST 36) and Hegu (LI 4) points and sham EA as control were administered by an experienced and licensed acupuncturist.

DESIGN

This was a pilot study with a randomized, single-blinded design.

SUBJECTS AND SETTING

Nineteen (19) patients with type 2 diabetes who had had symptoms of gastroparesis for more than 3 months were included in the trial and randomized into two groups. Each group received EA (n = 9) or sham EA (n = 10) consisting of 4 sessions over 2 weeks.

OUTCOME MEASURES

Symptom severity was evaluated using the Gastroparesis Cardinal Symptom Index (GCSI) at baseline, at the end of treatment, and 2 weeks after the end of the trial; solid-phase gastric half-emptying time was measured by scintigraphy; in addition, serum gastrin, motilin, PP, fasting, and postprandial blood glucose levels were also measured.

RESULTS

Gastric half-emptying time in 9 patients with diabetic gastroparesis was significantly shortened by EA treatment (143.8 +/- 55.9 minutes versus 98.8 +/- 28.6 minutes, p < 0.03). Half-emptying time did not change (98.9 +/- 26.4 minutes versus 90.9 +/- 24.8 minutes, p > 0.05) in the sham EA group. Symptom severity, as measured by GCSI total score, improved significantly both at the end of treatment (2.38 +/- 0.56 versus 1.48 +/- 0.19, p < 0.001) and 2 weeks after the end of the trial (2.38 +/- 0.56 versus 1.65 +/- 0.44, p < 0.01) when compared with the baseline in the EA group, but did not change from baseline with sham EA treatment. There were no significant changes in fasting and postprandial blood glucose, serum gastrin, motilin, and PP in both groups. No significant adverse events occurred.

CONCLUSIONS

This study demonstrates that short-term EA at the Zusanli and Hegu points effectively reduces the dyspeptic symptoms of diabetic gastroparesis and accelerates solid gastric emptying. Sustained improvement in dyspeptic symptoms was observed at 2 weeks after the end of the trial. Its potential for treating gastroparesis may be explored, and a larger trial is required to draw definitive conclusions.

Gastric electrical stimulation is an effective and safe treatment for medically refractory gastroparesis

BACKGROUND

Gastroparesis is characterized by delayed gastric emptying in the absence of obstruction. Common symptoms include nausea, vomiting, and abdominal pain. Severe gastroparesis can result in recurrent hospitalizations, malnutrition, and even death. Gastric electrical stimulation (GES) is a low morbidity treatment that may be effective in patients who are refractory to medical therapy.

METHODS

For a period of more than 35 months, 19 GES systems were implanted laparoscopically for refractory gastroparesis of diabetic (DG, n = 10), idiopathic (IG, n = 6), or postsurgical (PSG, n = 3) etiology. Total gastroparesis symptom scores (TSS) and weekly vomiting frequency were assessed. Gastric emptying studies were attained preoperatively and after 6 months.

RESULTS

Mean follow-up was 38 weeks. There were no major complications. Within 6 weeks, frequency of vomiting decreased in 75% of DG (6/8) and 100% of IG (4/4) patients. No PSG patient complained of vomiting preoperatively. Mean TSS scores improved significantly at all intervals out to 1 year. Gastric emptying studies normalized in 80% of DG patients but in only 1 of the 6 patients with gastroparesis due to other causes.

CONCLUSION

GES therapy can lead to improvement in symptoms of gastroparesis and frequency of vomiting within 6 weeks. This therapy is a low morbidity treatment option that may help patients whose symptoms fail to improve with medical therapy.

Pyloric injection of botulinum toxin for the treatment of refractory GERD accompanied with gastroparesis: a preliminary report

Gastroesophageal reflux disease (GERD) refractory to conventional medical treatment is frequently associated with gastroparesis, a complex condition with no definitive treatment to date. We first developed a scoring system to assess the severity and frequency of both reflux- and gastroparesis-related symptoms. We then tested, for the first time, the hypothesis that endoscopic pyloric botulinum toxin injection alleviates both of these symptom types. Eleven patients (four males) with GERD (confirmed by esophageal pH monitoring) plus gastroparesis (confirmed by gastric emptying study) underwent toxin injection. Patients had no concomitant disease and were not allowed to use prokinetics before or after treatment. Injection significantly improved both gastroparesis- and reflux-related symptoms in the majority of patients but the duration of symptom relief was relatively short. Responders to treatment had significantly higher total reflux symptom scores (before injection) than nonresponders. All but one of the patients in whom gastroparesis symptoms improved also showed response in reflux symptoms, which supports our hypothesis. We believe that response to toxin injection is a reliable predictor of response to subsequent surgery following the recurrence of symptoms.

Are gastrointestinal symptoms related to diabetes mellitus and glycemic control?

Many patients with diabetes mellitus suffer from upper and lower GI symptoms. The reported prevalence of these symptoms varies among different ethnic groups/populations. The natural history of GI symptoms as well as their pathogenesis in patients with diabetes remains poorly understood, although it is known that gastric emptying is influenced by hyperglycemia, euglycemia, and hypoglycemia. Poor glycemic control over a long period of time can lead to neuropathy and damage the vagus nerve, resulting in diabetic gastroparesis whose signs and symptoms vary in the individual patient. Gastroparesis can further worsen glycemic control by adversely altering the pharmacokinetics of orally administered hypoglycemic agents as well as by altering the delivery of diet-derived calories to intestines from which absorption, subsequently, determines incipient blood glucose, and thus effectiveness of various injectable antidiabetics including various insulins and related insulin analogs. As GI symptoms may overlap with other disorders, including functional dyspepsia, irritable bowel syndrome, and depression, it is important to have such patients/patients with diabetes undergo standardized testing for measuring gastric emptying. Certain medications including metformin, amylin analogues (i.e. pramlintide), glucagon-like peptide 1 analogs (i.e. exenatide, liraglutide), anticholinergic agents, antidepressants, calcium-channel blockers, and others may contribute to GI symptoms observed in patients with diabetes. Given the global diabetes pandemic, it is of utmost importance to not only diagnose and treat present patients with diabetes mellitus and its comorbidities, but also to help prevent the development of further disease burden by educating children and adolescents about healthy lifestyle modifications (avoidance of overeating, portion control, healthy food choices, increased physical and reduced sedentary activity), as changing behavior in adulthood has proven to be notoriously difficult.

Predictive factors for clinical improvement with Enterra gastric electric stimulation treatment for refractory gastroparesis

The objectives of this study were to determine the clinical response to Enterra gastric electric stimulation (GES) in patients with refractory gastroparesis and to determine factors associated with a favorable response.

METHODS

This study was conducted in patients undergoing Enterra GES for refractory gastroparesis. Symptoms were scored before and after GES implantation using the Gastroparesis Cardinal Symptom Index (GCSI) with additional questions about abdominal pain and global clinical response.

RESULTS

During an 18-month period, 29 patients underwent GES implantation. Follow-up data were available for 28 patients, with average follow-up of 148 days. At follow-up, 14 of 28 patients felt improved, 8 remained the same, and 6 worsened. The overall GCSI significantly decreased with improvement in the nausea/vomiting subscore and the post-prandial subscore, but no improvement in the bloating subscore or abdominal pain. The decrease in GCSI was greater for diabetic patients than idiopathic patients. Patients with main symptom of nausea/vomiting had a greater improvement than patients with the main symptom of abdominal pain. Patients taking narcotic analgesics at the time of implant had a poorer response compared to patients who were not.

CONCLUSIONS

GES resulted in clinical improvement in 50% of patients with refractory gastroparesis. Three clinical parameters were associated with a favorable clinical response: (1) diabetic rather than idiopathic gastroparesis, (2) nausea/vomiting rather than abdominal pain as the primary symptom, and (3) independence from narcotic analgesics prior to stimulator implantation. Knowledge of these three factors may allow improved patient selection for GES.

Management of gastroparesis

Gastroparesis presents with nausea, vomiting, early satiety and abdominal discomfort, as well as a range of nongastrointestinal manifestations in association with delays in gastric emptying. The disorder may be a consequence of systemic illnesses, such as diabetes mellitus, occur as a complication of gastroesophageal surgery or develop in an idiopathic fashion and may mimic other disorders with normal gastric emptying. Some cases of idiopathic gastroparesis present after a viral infection. Management relies primarily on therapies that accelerate gastric emptying or reduce vomiting, although endoscopic or surgical options are available for refractory cases. Current research is focusing on the cellular and molecular mechanisms underlying development of delayed gastric emptying, as well as factors unrelated to motor dysfunction that may elicit some symptoms. Future pharmaceuticals will target the contractile and nonmotor defects via novel pathways. Novel electrical stimulation techniques will be employed either alone or in combination with medications.

A novel classification scheme for gastroparesis based on predominant-symptom presentation

AIM

Symptoms of gastroparesis are very diverse. Classifying patients by predominant symptom may improve management strategy.

GOAL

To validate a new symptom-predominant classification for gastroparesis using symptom severity and quality-of-life measures.

STUDY

Subjects with gastroparesis for >2 months were prospectively enrolled. A physician classified each subject into one of the following: vomiting-predominant, dyspepsia-predominant, or regurgitation-predominant gastroparesis. Subjects also classified themselves independently from the physician. Each subject completed a Patient Assessment of Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) and SF-12v2 Health-Related Quality-Of-Life survey. Receiver operating characteristic curves were constructed with sensitivity and specificity of each PAGI-SYM subscale to differentiate subjects into symptom-predominant subgroups. Area under the curve (AUC) was used to compare the receiver operating characteristic curves. Analysis of variance, Cohen's kappa (kappa) statistic, student t test, and Pearson correlation (r) were used.

RESULTS

One hundred subjects (87 females, mean 48 y) were enrolled. There was a 78% concordance between physician and subject's classification of gastroparesis with substantial correlation (kappa=0.64). PAGI-SYM nausea/vomiting subscale (AUC=0.79) and PAGI-SYM heartburn/regurgitation subscale (AUC=0.73) were the best in differentiating subjects into vomiting-predominant and regurgitation-predominant gastroparesis, respectively. No subscale was adequate to differentiate dyspepsia-predominant gastroparesis. SF-12v2 total scores significantly correlated with worsening of the total PAGI-SYM scores (r=-0.339 to -0.600, all P<0.001).

CONCLUSIONS

There was a substantial agreement between physician and patient using a symptom-predominant gastroparesis classification. Results suggest that a predominant-symptom classification is a valid means to categorize subjects with vomiting-predominant and regurgitation-predominant gastroparesis. Patients with dyspepsia and delayed gastric emptying need further research.