Diabetic gastroparesisv2011
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Diabetic Gastroparesis adversely affects 20-40% of longstanding type 1 diabetics and may worsen blood glucose control, but our diabetic patients may not have any other symptoms! Discover the effects of high and low sugar on the normal and neuropathic gut, and learn what you can do help manage this difficult disorder.
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Diabetic gastroparesisv2011
- 1. Diagnosing & Managing Diabetic Gastroparesis Patricia L. Raymond MD FACP FACG • Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School • Gastroenterology Consultants, a division of Gastrointestinal & Liver Specialists of Tidewater pllc
- 2. Recognize the evil that is stalking your patients?
- 3. GI tract among many organ systems affected by diabetic autonomic neuropathy • Cardiovascular • Genitourinary • Neuroendocrine • Gastrointestinal tract • Upper • Lower
- 4. How frequent are gastrointestinal symptoms in diabetics? • 1101 subjects from outpatient clinics and the community • GI symptoms associated with autonomic or peripheral neuropathy (OR 1.62-2.39) • Constipation 29% • GERD 19% • Dyspepsia 14% • Abdominal pain 11% • Fecal incontinence 9% Bytzer, P. Am J Gastroenterol 2002; 97:604.
- 5. ACG 2011 Abstract #468: Economic Burden of Diabetic Gastroparesis • 3498 hospitalizations in 2006 • $2293 per hospitalization • $76 million annually
- 6. Esophageal involvement • GERD from autonomic neuropathy with decreased LES pressure, impaired peristaltic clearance of esophagus, delayed gastric emptying • Normals with hypergycemia (15 mm/l, 8 mm/l) with impaired transit and elevated TLESRs compared with euglycemia Rayner, CK. Diabetes Care 2001; 24:371.
- 7. Definition: Diabetic Gastroparesis • Synonyms: Gastric stasis, delayed gastric emptying • Symptoms: Nausea, vomiting, early satiety, bloating, weight loss, difficult glycemic control • Gastroparesis types: Diabetic, post viral, electrolyte imbalance, hypothyroid,idiopathic
- 8. Diabetic Gastroparesis • True prevalence unclear • 20-40% of diabetics, especially long standing type I • Magnitude of delay does not correlate with symptoms • Lack symptoms from neuropathy afferent sensory nerve fibers • Hyper-reactive symptoms • Results in poor glycemic control
- 11. Blood glucose affects gastric contractions • Normal, non diabetic subjects • Gastric contractions nearly absent at 250 mg/dl • Markedly reduced at 140 and 175 mg/dl Barnett, JL. Gastroenterology 1988; 94:739.
- 12. Fast = Goes fast! • Hypoglycemia leads to accelerated gastric emptying even in patients with delay in gastric emptying Russo, A. J Clin Endocrinol Metab 2005; 90:4489.
- 14. Just too sensitive? • Increased sensitivity with elevated blood glucose within physiologic range • Esophagus • Threshold for perception of balloon distension lowered • Stomach • Nausea, fullness, epigastric pain Rayner, CK. Diabetes Care 2001; 24:371. Parkman, HP. Gastroenterology 2004; 127:1592.
- 16. Diagnosis of Gastroparesis • EGD • Scintigraphy • Solid • Liquid • Both • Rare testing • EGG (Electrogastrogram), MRI, US, Isotope breath testing • (only done at some motility centers)
- 18. Taking a peek!
- 19. Not Gastroparesis: Pyloric Obstruction • Pyloric stenosis • Pyloric channel or stricture ulcer
- 20. Pyloric Cancer
- 21. Suggestive of Gastroparesis • Bezoar • Limited • Trichobezoar peristalsis • Pytobezoar • Gastric pool (saliva and gastric juices)
- 22. Diagnosis Scintigraphy GES Measure actual emptying time • Oatmeal • Egg Salad • Beef Stew • Technetium-99
- 23. Scintillating Syntigraphy Every hospital has own technique and normal values Cannot compare between hospitals Some do liquid phase emptying also
- 25. Watch out! • Poor correlation between magnitude of delay and symptoms • No data to support improving assymptomatic gastroparesis • improves long term diabetes control or prevents diabetes complications • Treat for symptom relief Stacher, G. J Clin Endocrinol Metab 1999; 84:2357.
- 26. Treatment of Gastroparesis • Dietary maneuvers • Low residue • aka the Twinkie ® diet • Take a hike • Medications • Endoscopic treatment/Botox • Gastric pacemaker • Feeding tube
- 28. Low residue diet You should avoid: • Whole-grain breads, cereals and pasta • Whole vegetables and vegetable sauces • Whole fruits, including canned fruits • Seeds and nuts
- 30. Take a hike • Postprandial walking • 50 patients with DM • Emptying rates of 28 patients (56%) were within normal range of controls • 4 patients with accelerated emptying (8%). • 18 patients with delayed emptying (36%) Lipp, R. W. American Journal of Gastroenterology 2000; 95(2), 419–424.
- 31. Postprandial walking • Two variants of delayed gastric emptying (18 of 50 patients): • Counteracted by postprandial walking in 7 patients (39% of GP) • Not influenced by postprandial walking in 11 patients (61% of GP)
- 33. Medications • Erythromycin • Reglan/promethazine • Cisapride • Domperidone • Antiemetics
- 34. Erythromycin • Erythromycin • 3mg/kg IV over 45 min to ‘kick-start’ stomach • High amplitude gastric propulsive contractions which dump solid residue out of stomach • Evidence for po Erythro weak • 35 trials, only 5 ‘fulfilled inclusion criteria’, all small #,all short (< 4 weeks) • Improvement in 26 of 60 patients (43%) Prather, CM. Am J Physiol 1993; 264:G928. Keshavarzian, A. Am J Gastroenterol 1993; 88:193. Maganti, K. Am J Gastroenterol 2003; 98:259.
- 35. Erythromycin potential side effects • GI toxicity • Ototoxicity • Pseudomembranous colitis • Resistant bacterial strains • Sudden death due to prolonged QT interval
- 36. ACG 2011 Abstract # 875: Azithromycin verses Erythromycin • 13 patients, • AZI may be crossover trial better due to • 100 mg AZI • longer half life • Breath-testing • better SE profile prior to • lack P450 crossover interaction • Findings: Bioequivalent
- 37. 1-800-SoSueMe: Reglan • PO or SQ • Tardive dyskinesia • Irritability, anxiety, depression, hyperprolactinemia • 2010 meta analysis UK & Sweden tardive dyskinesia <1%, may be reversible if caught early Rao, AS. Aliment Pharmacol Ther 2010; 31:11.
- 38. Reglan/Metaclopramide po: Start low, give holidays • 5mg 15 minutes • Notify MD for AC and HS any involuntary • Titrate upward movement (to 40 mg/day) • Early • Consider liquid recognition and version, SQ drug • Drug holidays discontinuation or occasional may lead to dose reductions resolution
- 39. Cisapride and Zelnorm: Can’t Get No Satisfaction • Cisapride: QT interval issues with cardiac arrhythmias and death • 5HT3 receptor agonist • Increased solid and liquid emptying in various gastric stasis conditions • More potent and better tolerated than reglan • Zelnorm: Yanked by FDA
- 40. Oh Canada! Domperidone • Not FDA approved for use in the US • Can be obtained through IND application • May be compounded by local pharmacists or purchased overseas by internet • Efficacy similar to metaclopramide • Cardiac arrhythmias in animal studies
- 41. ACG 2011 Abstract #878: Domperidone at Walter Reed • 13 patients • 54% improved on domperidone • Dosage 20 to 80 mg daily (median 40 mg daily) • No QT changes, no SE, no lab abnormalities
- 43. Antiemetics • Antihistamine • Diphenhydramine (Benadryl) • Oral or rectal • Phenothiazines • Compazine • IV or rectal • HT3 Antagonists • Ondansetron (Zofan), granisitron (Kytril) no advantage over conventional agents
- 44. Endoscopy with botox • Pilot studies injecting botox into pylorus helped gastric emptying
- 45. Rethinking botox • Controlled trial 32 patients • No difference in emptying or symptoms compared with placebo at 1 month • Crossover trial 23 patients • No improvement symptoms or rate of gastric emptying • “Larger, controlled trials are needed” Friedenberg, FK. Am J Gastroenterol 2008; 103:416. Arts, J. Aliment Pharmacol Ther 2007; 26:1251.
- 46. Abstract #467 ACG 2011: Botox or Pyloric Balloon with Normal 3 cpm EGG • 18 patients with • 15 improved after normal EGG slow 2 interventions, 3 GES, normal EGD no response • 4 quadrant botox • Symptom free for 100 mcg or 20 mm 4 months average balloon x 2 • Retreatment at minutes relapse • If no symptom improvement, other intervention done
- 49. The lure of gastric pacemakers • Photo gastric • Better pacemaker symptoms, but no improvement in emptying • Limited efficacy, humanitarian use device Abell, T. Gastroenterology 2003; 125:421. McCallum, R. Gastroenterology 2009; AB376.
- 50. ACG 2011 Abstract #877: Mucosal Nerve Fiber Density • 5 GP patients (1 • MNF density DM, 2 idiopathic, 2 reduced in post-op), 3 age GP.0018 vs .0024 matched controls (p=.02) • GP patients had • MNF density full thickness correlates with biopsies at pacer symptom severity implant • MNF density correlates with duration of disease
- 52. Last ditch- the jejenostomy tube or decompressive PEG • Rarely needed
- 54. What evils are following your patients?
- 55. Gastroparesis • Symptoms don’t correlate with degree of emptying impairment • EGD and scintigraphy to diagnose • Lifestyle changes as mainstay of treatment • Reglan not as evil as previously supposed, newer management continues to be a ‘wash out’