Efficacy of gastric electrical stimulation in improving functional vomiting in patients with normal gastric emptying

Comparing the prevalence and association between anxiety, depression and gastrointestinal symptoms in gastroparesis versus functional dyspepsia: A systematic review and meta-analysis

OBJECTIVE

To determine the prevalence and associations between anxiety/depression, and gastrointestinal (GI) symptoms across gastroparesis and functional dyspepsia.

METHODS

Twenty adult studies were identified through systematic searches of three databases (PubMed, CINAHL and PsycINFO) in September 2023. Meta-analysis was performed to estimate the pooled prevalence rates of anxiety and depression across gastroparesis and functional dyspepsia, and to determine whether the associations of anxiety/depression and gastrointestinal (GI) symptoms differ in gastroparesis versus functional dyspepsia.

RESULTS

The overall pooled prevalence rate for anxiety was similar (χ2(1) = 2.45, p = .12) in gastroparesis (49%) and functional dyspepsia (29%). The overall pooled prevalence rate for depression in gastroparesis (39%), and functional dyspepsia (32%) was also similar (χ2(1) = 0.81, p = .37). No significant relationship between anxiety and GI symptoms (r = 0.11) or depression and GI symptoms (r = 0.16) was found in gastroparesis, whilst significant, though weak, positive relationships between anxiety and GI symptoms (r = 0.30) and depression and GI symptoms (r = 0.32) were found in functional dyspepsia. The association between GI symptoms and anxiety, but not depression, across gastroparesis and functional dyspepsia was found to be significant (χ2(1) = 5.22, p = .02).

CONCLUSION

Contributing to ongoing debate as to whether gastroparesis and functional dyspepsia are interchangeable syndromes, this review found that anxiety and depression prevalence was similar in both conditions. Psychological assessment and the utilisation of effective and holistic care in both conditions is therefore warranted.

Gastric Electrical Stimulation: Role and Clinical Impact on Chronic Nausea and Vomiting

Gastric electrical stimulation (GES) is currently used as an alternative treatment for medically refractory gastroparesis. GES has been initially developed to accelerate gastric motility, in order to relieve the symptoms of the patients. Subsequent studies, unfortunately, failed to demonstrate the acceleration of gastric emptying using high-frequency stimulation - low energy stimulation although the technique has shown a clinical impact with a reduction of nausea and vomiting for patients with gastroparesis. The present review details the clinical efficacy of GES in gastroparesis as well as its putative mechanisms of action.

Gastric electrical stimulation improves symptoms and need for supplemental nutrition in children with severe nausea and vomiting: A ten-year experience

BACKGROUND

Gastric electrical stimulation (GES) is a promising therapy for children with severe nausea and vomiting, but information on long-term outcomes is limited. We sought to evaluate the long-term efficacy and safety of GES and to describe patient benefit and satisfaction.

METHODS

Using a prospective registry, we identified patients aged <21 years treated with GES at our institution between 2009 and 2019. Encounters were selected at baseline prior to GES and at follow-up at 1 month, 12 months, and the most recent visit. We compared symptoms, route of nutrition, and medication usage at baseline to follow-up timepoints. Factors associated with improvement were evaluated. We recorded complications and need for battery replacement. We contacted families to administer the Glasgow Children's Benefit Inventory (GCBI) and a parent satisfaction questionnaire.

KEY RESULTS

Eighty-five patients (68.2% female, median age 15.8 years) completed a trial of temporary GES due to severe nausea and vomiting. Seventy-seven (90.6%) had a positive response and underwent permanent stimulator placement. Use of tube feeding or parenteral nutrition (PN) decreased from 72.7% at baseline to 29.9% at the most recent follow-up (p < 0.001). Higher baseline vomiting severity was associated with the ability to stop supplemental nutrition by 1 month (p < 0.05). Fourteen patients (18.2%) had complications, primarily due to stimulator-associated discomfort, and 29 (37.7%) required battery replacement. Median GCBI was +52.1, indicating health-related benefit.

CONCLUSIONS AND INFERENCES

Children with severe nausea and vomiting treated with GES experienced significant and durable improvement in symptom severity and their ability to tolerate oral nutrition.

Efficacy of gastric electrical stimulation in intractable nausea and vomiting at 10 years: A retrospective analysis of prospectively collected data

BACKGROUND

Gastric electrical simulation has been shown to relieve nausea and vomiting in medically refractory patients. Efficacy of gastric electrical stimulation has been reported mostly in short-term studies, but none has evaluated its efficacy beyond 10 years after implantation.

METHODS

Patients implanted at our center for medically refractory severe and chronic nausea and/or vomiting were evaluated before and over 10 years after implantation using symptomatic scale and quality of life (GIQLI) score. Improvement was defined as a reduction of more than 50% in vomiting frequency.

KEY RESULTS

A total of 50 patients were implanted from January 1998 to December 2009. Among them, 7 were explanted due to a lack of efficacy and/or side effects, 2 died, and 4 were lost to follow-up. Mean follow-up was 10.5 ± 3.7 years. In intention-to-treat analysis, 27/50 (54%) patients reported an improvement. Beyond 10 years, an improvement in early satiety (3.05 vs 1.76, <0.001), bloating (2.51 vs 1.70, P = .012), nausea (2.46 vs 1.35, P = .001), and vomiting (3.35 vs 1.49 P < .001) scores were observed. Quality of life improved over 10 years (GIQLI score: 69.7 vs. 86.4, P = .005) and body mass index (BMI: 23.4 vs. 26.2 kg/m² ; P = .048).

CONCLUSIONS AND INFERENCES

Gastric electrical simulation is effective in the long-term in patients with medically refractory nausea and vomiting, with an efficacy of 54% at 10 years on an intention-to-treat analysis. Other long-term observational studies are warranted to confirm these results.

Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and Vomiting

Background/Aims

Recurrent nausea and/or vomiting are common complications of diabetes mellitus. The conditions severely impact the quality of life of patients and often cause repeated admissions to hospital incurring significant healthcare costs. If standard treatment fails, gastric electrical stimulation (GES) may be offered in selected cases, as a minimally invasive, but expensive, therapeutic option. Our aims are to evaluate the clinical effect and the cost-utility of GES as a treatment for severe diabetic recurrent nausea and/or vomiting.

Methods

Among 33 diabetes patients implanted with GES because of recurrent nausea and/or vomiting, 30 were available for evaluation. The effect of treatment was assessed prospectively using symptom-diaries and the SF-36 questionnaires at baseline, after 6 and 12 months, and thereafter yearly. The number of days in hospital due to symptoms related to gastrointestinal dysfunction was calculated using hospital records 12 months prior to and 12 months after implantation.

Results

The surgical procedures were performed without mortality or major complications. Six months after surgery 78% of the respondents had at least 50% reduction in time with nausea and 48% had at least 50% reduction in days with vomiting. Symptom relief persisted at follow-up after at least 4 years. Quality adjusted life years improved after GES, which was cost-effective after 24 months.

Conclusions

GES reduces symptoms and improves quality of life in diabetes patients with recurrent nausea and/or vomiting. The procedure is supposed as cost-effective over a 2-year time horizon.

Gastrointestinal Peptides During Chronic Gastric Electrical Stimulation in Patients With Intractable Vomiting

OBJECTIVES

Gastric electrical stimulation (GES) is an alternative therapy to treat patients with intractable vomiting. A preclinical study has demonstrated the modulation of the gastrointestinal (GI) peptide ghrelin by GES but such mechanism has never been investigated in patients. The aim of this work was to assess the effect of GES on GI peptide levels in patients with intractable vomiting.

MATERIALS AND METHODS

Twenty-one patients were randomized to receive either ON or OFF GES, 14 completed the study (10 ON, 4 OFF stimulation). Vomiting episodes, gastric emptying, and gastrointestinal quality of life index (GIQLI) were assessed. Gastric and blood samples were collected before and four months after the ON period of gastric stimulation. mRNA and/or peptide levels were assessed in gastric biopsies for ghrelin, leptin, and NUCB2/nesfatin-1 and in duodenal biopsies for glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) using RT-qPCR and multiplex technology. Ghrelin, leptin, GLP-1, PYY, gastric inhibitory peptide (GIP), and NUCB2/nesfatin-1 levels also were quantified in blood samples.

RESULTS

Among clinical parameters, vomiting episodes were slightly reduced by GES (p = 0.09). In tissue, mRNA or protein levels were not modified following chronic GES. In blood, a significant reduction of postprandial PYY levels (p < 0.05) was observed at M4 and a reduction of NUCB2/nesfatin-1 levels in fasted patients (p < 0.05). Increased plasma leptin levels after GES were correlated with reduction of vomiting and improvement of GIQLI.

CONCLUSIONS

GES reduces NUCB2/nesfatin-1 levels under fasting conditions and postprandial PYY levels in patients suffering from nausea and/or vomiting refractory to pharmacological therapies.

Gastric Electrical Stimulation for Gastroparesis and Chronic Unexplained Nausea and Vomiting

OPINION STATEMENT

Gastroparesis is a heterogeneous clinical syndrome. Some patients have debilitating vomiting, weight loss, and dehydration, while others have effortless regurgitation of undigested foods or postprandial distress suggestive of functional dyspepsia. Gastric electrical stimulation (GES) has been proposed as an effective treatment option for patients with gastroparesis refractory to medical therapy. Evidence suggests that the clinically available device, a low-energy high-frequency GES, activates the vagal afferent pathways to influence the central control mechanisms for nausea and vomiting. Myoelectrical effects of the stomach are also involved. The results of randomized controlled trials (RCTs) for adults with diabetic and idiopathic gastroparesis are conflicting. There are no RCTs in adults with chronic unexplained nausea and vomiting (CUNV) with normal gastric emptying or in children with gastroparesis. However, there is increasing evidence from large unblinded studies showing the long-term efficacy in selected adults with gastroparesis. Selection criteria should be based on three categories: (a) underlying etiology, (b) clinical presentation and predominant symptoms, and (c) potential risk for complication. Significant abdominal pain, daily opiate use, and idiopathic gastroparesis are identified as negative predictors of success. Temporary GES has been utilized to identify patients who may benefit from surgical GES, but this strategy has yet to be proven in controlled studies. Objectives for this review are to highlight the mechanisms of action for GES, to look at the evidence for clinical efficacy, and to select patients who are likely to benefit.

Motility: Is 'ICC-opathy' present in gastroparesis-like syndrome?

The impact of chronic nausea and vomiting on quality of life and economic burden are substantial. New findings show that interstitial cells of Cajal are depleted or have ultrastructural changes in patients with chronic nausea and vomiting who have normal gastric emptying. Abnormalities of the gastric slow waves were also observed.

Improvement of quality of life and symptoms after gastric electrical stimulation in children with functional dyspepsia

BACKGROUND

Our objective is to evaluate the effect of gastric electrical stimulation (GES) on symptoms and quality of life for pediatric patients with functional dyspepsia (FD).

METHODS

Twenty-four patients (16 female, median 15 years) were treated with GES for FD after a median of 24 months of symptoms (3 months-14 years). At baseline, 46% required tube feeds and 25% parenteral nutrition. Sixty percent had gastroparesis. The PedsQL GI Module (PedsQL) was completed for 18/24 both pre-/post-GES after a median of 8 months. Patients also completed the Symptom Monitor Worksheet (SMW) pre-/post-GES after a median of 6 months. Pre-/post-GES global health was also assessed.

KEY RESULTS

Significant improvements were seen in multiple areas of the PedsQL, including stomach pain/upset, food/drink limits, heartburn/reflux, gas/bloating, patient worry, medication tolerance, and constipation (P < 0.05). A decrease was found in combined symptom severity/frequency based on SMW (P < 0.01). Improvements were made in all categories, including vomiting, nausea, early satiety, bloating, fullness, epigastric pain, and burning (P < 0.01). Improvements in PedsQL/SMW scores remained when analysis was limited to normal or delayed gastric emptying (P < 0.05, P < 0.05). Thirteen percent needed tube feeds and 13% parenteral nutrition after GES. Sixty-five percent reported that their health was much improved after GES vs 15% the same or worse. Five patients experienced complications, primarily mild abdominal discomfort.

CONCLUSIONS & INFERENCES

In the largest series to date of pediatric patients who have undergone GES for FD, we found significant improvements in upper gastrointestinal symptoms, quality of life, and perception of global health. Patients were less dependent on tube feeding or parenteral nutrition.

Gastric electrical stimulation increases the discomfort threshold to gastric distension

INTRODUCTION

Gastric electrical stimulation (GES) is now considered as a new therapeutic alternative for patients with medically refractory vomiting and/or nausea, although its mechanisms of action remain poorly understood.

METHODS AND PATIENTS

Gastric discomfort threshold, measured as the gastric maximal tolerable volume (MTV) to distension, was examined before and after GES, in nine patients implanted for chronic and severe nausea and vomiting.

RESULTS

GES increased gastric MTV from 522 ± 64 ml at baseline to 628 ± 60 ml 6 months after the start of GES (P=0.03), whereas gastric emptying remained unchanged. The increase in MTV was correlated with symptoms and quality of life at 6 months, whereas gastric emptying was not. Finally, MTV varied in a similar manner at 6 months in patients with delayed and normal gastric emptying measured before implantation.

CONCLUSION

Taken together, these data indicate that modification of gastric sensation to distension, rather than gastric emptying, is associated with symptoms' outcome during GES.

Gastric electrical stimulation decreases gastric distension-induced central nociception response through direct action on primary afferents

Background & Aims

Gastric electrical stimulation (GES) is an effective therapy to treat patients with chronic dyspepsia refractory to medical management. However, its mechanisms of action remain poorly understood.

Methods

Gastric pain was induced by performing gastric distension (GD) in anesthetized rats. Pain response was monitored by measuring the pseudo-affective reflex (e.g., blood pressure variation), while neuronal activation was determined using c-fos immunochemistry in the central nervous system. Involvement of primary afferents was assessed by measuring phosphorylation of ERK1/2 in dorsal root ganglia.

Results

GES decreased blood pressure variation induced by GD, and prevented GD-induced neuronal activation in the dorsal horn of the spinal cord (T9–T10), the nucleus of the solitary tract and in CRF neurons of the hypothalamic paraventricular nucleus. This effect remained unaltered within the spinal cord when sectioning the medulla at the T5 level. Furthermore, GES prevented GD-induced phosphorylation of ERK1/2 in dorsal root ganglia.

Conclusions

GES decreases GD-induced pain and/or discomfort likely through a direct modulation of gastric spinal afferents reducing central processing of visceral nociception.

Long term efficacy of gastric electrical stimulation in intractable nausea and vomiting

BACKGROUND

Although the efficacy of gastric electrical stimulation has been reported in short-term studies, there is a lack of data on the long-term improvement of nausea and vomiting by gastric electrical stimulation in patients with delayed or normal gastric emptying.

METHODS

Thirty-one patients were implanted at our centre for medically refractory severe and chronic nausea and/or vomiting. Patients were evaluated at baseline, 6 months then 5 years after implantation (mean follow-up 80±4 months) using a symptomatic and quality of life scores.

KEY RESULTS

Amongst the 31 patients, 4 were lost to follow-up, 6 explanted due to lack of improvement, and 1 patient died. Out of the 20 patients evaluated over 5 years, the quality of life score showed 27% improvement (p<0.01), including nausea (62%; p<0.01), vomiting (111%; p=0.03), satiety (158%; p<0.01), bloating (67%; p<0.01) and epigastric pain (43%; p=0.03). Over 5 years, 15/20 patients reported a 50% improvement with a global satisfaction rated at 64±6%. Therefore, 15/27 patients (56%) were improved by gastric electrical stimulation over 5 years in intention to treat. Improvement of nausea 6 months after implantation was predictive of 5-year success of gastric electrical stimulation (p=0.04). Finally, patients with delayed gastric emptying or with normal gastric emptying rate before surgery were similarly improved over 5 years (60% versus 50% respectively).

CONCLUSION

Gastric electrical stimulation is safe and effective in the long term in patients with medically refractory nausea and vomiting, with an efficacy over 50% beyond 5 years in intention to treat. Gastric emptying measured before implantation did not influence the response rate over 5 years.

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.

Gastric electrical stimulation increases ghrelin production and inhibits catecholaminergic brainstem neurons in rats

Gastric electrical stimulation (GES) is a new therapeutic option for functional dyspepsia and gastroparesis. In addition to ameliorating nausea and vomiting, GES results in improved appetite which is not always associated with accelerated gastric emptying. To explore the central and peripheral factors underlying GES-associated improvement of appetite we developed a GES model in anaesthetized Wistar rats. During laparotomy, two electrodes were implanted into the stomach and high-frequency low-energy GES (14 Hz, 5 mA) was applied. The effects of 1 h GES were compared with sham stimulation. After GES, c-Fos expression was increased in the mucosal and submucosal layers of the stimulated area (174%). In the stomach, GES increased ghrelin mRNA (178%) and doubled the number of ghrelin-positive cells, resulting in elevated plasma levels of ghrelin (2.3 ± 0.2 vs. 1.6 ± 0.2 ng/mL). In the arcuate nucleus of the hypothalamus, GES increased c-Fos (277%) and agouti-related protein (AgRP) mRNA expression (135%). GES reduced the number of c-Fos-positive cells throughout the nucleus of the solitary tract (between 93 and 75% from rostral to caudal levels) including catecholaminergic neurons (81% at caudal level). Gastric emptying, plasma glucose and heart rate variability were not affected by GES. This study shows that GES may improve appetite via stimulation of main orexigenic pathways, including ghrelin production in the stomach and AgRP in the hypothalamus, as well as by reducing the activity of catecholaminergic brainstem neurons.