Nasogastric tube insertion followed by intravenous and oral erythromycin in refractory nausea and vomiting secondary to paraneoplastic gastroparesis: A case report

Occult Non-small Cell Lung Cancer Presenting as Paraneoplastic Gastroparesis: A Case Report and Literature Review

Paraneoplastic gastrointestinal syndromes rarely precede the actual detection of an overt cancer with gastroparesis being a very rare initial presentation. To increase the clinical awareness of this rare clinical entity, we present a case of severe gastroparesis that was later proven to be associated with an occult poorly differentiated non-small cell lung cancer. We then continue to briefly review the relevant literature on paraneoplastic gastrointestinal syndromes to date.

A 61-year-old African-American man presented with two months history of severe post-prandial nausea, vomiting and bloating associated with unintentional weight loss of 20 pounds. General physical examination revealed cachexia, temporal muscle wasting and clubbing of nails in both hands. The following investigations were normal or negative: basic metabolic panel, liver function tests, chest X-ray and esophagogastroduodenoscopy. Computed tomography (CT) scan of the abdomen showed residual food in the stomach and scintigraphic gastric emptying studies were consistent with gastroparesis. CT scan of the chest was performed which revealed a spiculated nodule sized 9 mm in right upper lobe of the lung with right hilar lymphadenopathy. Positron emission tomography (PET) scan revealed hyper-metabolic activity in the right upper lobe nodule and right hilar adenopathy. Nodule resection and biopsy revealed a poorly differentiated non-small cell lung carcinoma. Due to the concern of paraneoplastic origin of his gastroparesis further serological testing showed positive anti-neuronal nuclear antibodies type 1 (Anti-Hu) and cytoplasmic purkinje cell antibodies (Anti-Yo). The patient was started on a chemotherapy combination of Carboplatin and Paclitaxel with a three-week course of local radiation therapy. Moreover, for the relief of his severe gastrointestinal (GI) symptoms dietary modifications, pro-kinetic agents and psychological counseling were used with gradual clinical improvement observed on follow-up visits.

Ghrelin and Motilin Control Systems in GI Physiology and Therapeutics

Ghrelin and motilin are released from gastrointestinal endocrine cells during hunger, to act through G protein-coupled receptors that have closely related amino acid sequences. The actions of ghrelin are more complex than motilin because ghrelin also exists outside the GI tract, it is processed to des-acyl ghrelin which has activity, ghrelin can exist in truncated forms and retain activity, the ghrelin receptor can have constitutive activity and is subject to biased agonism and finally additional ghrelin-like and des-acyl ghrelin receptors are proposed. Both ghrelin and motilin can stimulate gastric emptying, acting via different pathways, perhaps influenced by biased agonism at the receptors, but research is revealing additional pathways of activity. For example, it is becoming apparent that reduction of nausea may be a key therapeutic target for ghrelin receptor agonists and perhaps for compounds that modulate the constitutive activity of the ghrelin receptor. Reduction of nausea may be the mechanism through which gastroparesis symptoms are reduced. Intriguingly, a potential ability of motilin to influence nausea is also becoming apparent. Ghrelin interacts with digestive function through its effects on appetite, and ghrelin antagonists may have a place in treating Prader-Willi syndrome. Unlike motilin, ghrelin receptor agonists also have the potential to treat constipation by acting at the lumbosacral defecation centres. In conclusion, agonists of both ghrelin and motilin receptors hold potential as treatments for specific subsets of digestive system disorders.

Erythromycin: prophylaxis against recurrent small bowel obstruction

We describe three cases where erythromycin suspension has been used successfully in preventing recurrence of small bowel obstruction in patients with terminal illness and for whom it proved more effective than standard preparations such as metoclopramide and domperidone. These patients also experienced a longer term benefit over some months. With recent alerts over longer term use of metoclopramide and domperidone, we demonstrate that erythromycin is a viable alternative prokinetic in patients with terminal illness at risk of small bowel obstruction instead of or alongside metoclopramide and domperidone. More research is required to establish the point at which erythromycin should be considered in the management of symptoms. In addition, research into the possibility of a viable alternative to erythromycin is needed.