Nutritional considerations in the patient with gastroparesis

Prevalence and disease burden of gastroparesis in Asia

Gastroparesis is a gastrointestinal disorder characterized by significant prolongation of gastric emptying time caused by impaired motility of the stomach. Its estimated prevalence is 24.2 per 100 000 people. However, the prevalence of gastroparesis in Asian countries is unknown due to a limited number of epidemiological studies and significant phenotypic variability of the Asian population in these studies. Analysis of previous research on gastroparesis and functional bowel disorders reveals the possibility of an increased prevalence among Asian individuals. A comparison of ethnic constituents between the recent United Kingdom gastroparesis study and its mother database has demonstrated a higher prevalence of gastroparesis among British Asian patients when compared with British Caucasian patients. An estimated gastroparesis prevalence in the Asian population can be calculated by identifying the individuals who are likely to demonstrate a delayed gastric emptying from all diagnosed functional dyspepsia patients. We suggest that gastroparesis tends to be underdiagnosed in Asians due to a lack of studies on gastroparesis in the Asian continent, a lack of knowledge among practitioners, and poor availability of scintigraphy testing as well as limited therapeutic options for this disease. Given the high probability of Asian predominance in gastroparesis and its disease impact on quality of life, epidemiological research focusing on the Asian population is required.

Diabetic Gastroparesis and its Emerging Therapeutic Options: A Narrative Review of the Literature

Diabetic gastroparesis (DG) is one of the many complications of diabetes mellitus (DM). Even though this condition surfaces years after uncontrolled disease, it affects the quality of life in several ways and causes significant morbidity. Common symptoms experienced by the patients include postprandial nausea, vomiting, abdominal fullness, and pain. Strict glycemic control is essential to evade the effects of DG. The purpose of this review article is to briefly study the pathophysiology, clinical features, diagnostic modalities, and the effects of DG on different aspects of life. Furthermore, it also focuses on the emerging treatment modalities for DG. Tradipitant and relamorelin are two such treatment options that are gaining noteworthy recognition and are discussed in detail in this review article. As observed through various clinical trials, these drugs help alleviate symptoms like nausea, vomiting, abdominal pain, and bloating in patients suffering from DG, thereby targeting the most common and bothersome symptoms of the disease. This leads to an improvement in the quality of life, making it a reliable treatment option for this disease. But while pharmacological intervention is vital, psychological support and lifestyle changes are equally important and are the reason why a multidisciplinary approach is required for the treatment of DG.

Hair Loss in Patients with Gastroparesis: A Sign of Nutritional Deficiency in Gastroparesis?

INTRODUCTION

Some patients with gastroparesis (Gp) report hair loss. The aim of this study was to investigate the prevalence of patient-reported hair loss in Gp patients, analyze hair loss association to severity of Gp and nutritional deficiencies, and study effects of multivitamin treatment on hair loss.

METHODS

Patients with Gp were questioned about hair characteristics, Gp symptoms, and diet. Patients with hair loss had blood drawn for vitamin levels. Patients with hair loss were treated with daily multivitamin and assessed 8 weeks later.

RESULTS

Hair loss was reported in 65 of 143 patients with Gp (45.5%), occurring similarly in idiopathic and diabetic Gp. Hair loss was most commonly noticed while washing and/or combing hair. Patients with hair loss had more severe nausea, abdominal pain, stomach fullness, loss of appetite, abdominal discomfort, bloating, retching, stomach distension, vomiting, early satiety, postprandial fullness, and constipation. Hair loss patients lost more weight over prior 6 months. Patients with hair loss had similar gastric retention on gastric emptying scintigraphy. Overall, 29 of 61 (47.5%) patients with hair loss had at least one abnormal bloodwork result. After 8 weeks of treatment with a daily multivitamin, 17 of 41 (41%) patients had improvement in hair loss.

CONCLUSION

Hair loss occurred in 46% of patients with Gp, being associated with more severe symptoms, loss of weight, and several vitamin deficiencies, although not a specific one. Treatment with multivitamins improved hair loss in 40% of patients. Presence of hair loss in patients with Gp should prompt nutritional evaluation and supplementation.

Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See?

Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.

The mechanism of esophagus dysmotility in diabetes and research progress of relating treatments

Introduction: Esophagus dysmotility is a crucial risk factor of gastroesophageal reflux disease (GERD), which is one of the most common diseases in digestive medicine globally. This review emphasizes the mechanisms of esophagus dysmotility in diabetes and summarizes more targeted treatments for these patients to avoid the overuse of proton pump inhibitors (PPIs).Areas covered: Diabetes mellitus (DM) is a clear factor that must not be neglected in the development of GERD. Previous studies have preliminarily researched the esophagus deterioration in diabetes. However, the multi-faceted mechanisms of esophagus dysmotility in diabetes need more studies. Besides, targeted treatments for these patients rather than conventional PPIs are urgently needed.Expert opinion: The treatments for GERD patients with diabetes should be further explored. Pharmacological approaches such as prokinetic agents, psychotherapy can be adopted. Meanwhile, it's feasible to explore non-drug treatments. For example, Electroacupuncture (EA) at Zusanli (ST-36) may be effective to protect the networks of intestinal cells of Cajal (ICCs) in diabetes. More effective approaches should be explored to achieve individualized treatment for these patients.

Body weight in patients with idiopathic gastroparesis

BACKGROUND

The classic clinical picture of gastroparesis is a symptomatic patient losing weight. In addition, a number of patients with delayed gastric emptying are obese and/or gaining weight. Our aim was to investigate the factors impacting body weight in patients with idiopathic gastroparesis.

METHODS

In patients with idiopathic gastroparesis, detailed history and weight were acquired at enrollment and after 48 weeks. Questionnaires assessed symptoms, food intake, physical activity, and quality of life. Patients underwent laboratory testing, gastric emptying scintigraphy, and water load testing.

RESULTS

Of 138 patients with idiopathic gastroparesis, 10% were underweight (BMI < 18.5), 39% were normal weight (BMI 18.5-25), 20% were overweight with BMI 25 to 30 kg/m² , and 29% were obese with BMI > 30 kg/m² . Body weight at enrollment was positively associated with oral caloric consumption (P < .001), following a gastroparesis diet (P = .04), nutrition consultation (P = .001), upper abdominal pain (P = .01); and negatively associated with energy expenditure (P = .05), alcohol use (P = .003) and severity of bloating (P < .001). When followed over 48 weeks, 53% patients stayed stable (within 5% of baseline weight), 30% gained, and 17% lost weight. Weight gain over 48 weeks was positively associated with oral caloric consumption (P = .003) and constipation severity (P = .005) at enrollment, and negatively associated with lower abdominal pain severity (P = .007) at enrollment, and associated with improvement in inability to finish meal score (P < .001) at 48 weeks.

CONCLUSIONS

In this series of patients with idiopathic gastroparesis, 10% were underweight whereas 29% were obese. Over 48 weeks, 30% of patients increased their body weight ≥ 5%. Diet, activity, and symptoms are important factors associated with body weight in patients with idiopathic gastroparesis.

Pathophysiology, Aetiology and Treatment of Gastroparesis

Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.

Diabetic Gastroparesis

This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.

Enteral Nutrients and Gastrointestinal Physiology

The gastrointestinal (GI) tract is a highly efficient organ system with specialized structures to facilitate digestion and absorption of nutrients to meet the body's needs. The presence of nutrients in the GI tract supports optimal structure and function, stimulates regulatory hormones, and supports the microbiota, the population of microorganisms residing in the GI tract. A lack of enteral nutrition (EN) results in impaired GI integrity and serious patient complications, making EN a priority. Normal GI physiology is reviewed, and the regulatory impact of luminal nutrients on GI function is discussed.

Outcomes of High-Frequency Gastric Electric Stimulation for the Treatment of Severe, Medically Refractory Gastroparesis in Finland

Background and Aims:

Severe, medically uncontrollable gastroparesis is a rare entity, which can be treated using a high-frequency gastric electric stimulator implanted surgically. Previous follow-ups have proven positive outcomes with gastric electric stimulator in patients with gastroparesis. The aim of this study was to evaluate the efficacy and safety of gastric electric stimulator in patients, in whom gastroparesis could not be controlled by conservative means in our country.

Materials and Methods:

This is a retrospective multi-center cohort comprising all patients who had been implanted gastric electric stimulator for severe, medically refractory gastroparesis during 2007–2015 in Finland.

Results:

Fourteen patients underwent implantation of gastric electrical stimulator without any postoperative complications. Laparoscopic approach was used in 13 patients (93%). Prior implantation, all patients needed frequent hospitalization for parenteral feeding, 13 had severe nausea, 11 had severe vomiting, 10 had notable weight loss, and 6 had frequent abdominal pain. After operation, none of the patients required parenteral feeding, 11 patients (79%) gained median of 5.1 kg in weight (P < 0.01), and symptoms were relieved markedly in 8 and partially in 3 patients (79%). Of partial responders, two continued to experience occasional vomiting and one mild nausea. Five patients needed medication for gastroparesis after the operation. One patient did not get any relief of symptoms, but gained 6 kg in weight. No major late complications occurred.

Conclusion:

Gastric electrical stimulator seems to improve the nutritional status and give clear relief of the symptoms of severe, medically uncontrollable gastroparesis. Given the low number of operations, gastric electrical stimulator seems to be underused in Finland.