Gastroparesis after surgery is a common clinical entity

1. History
•
•
•
•
•
4th Post op day
Nausea +
Vomiting:3episodes
Abdomen distended
Not passed flatus or motion

2. Post Surgical Gastroparesis
Presenter-Dr.Amit Goswami

3. Introduction
• Post prandial nausea and vomiting and
gastric atony without mechanical
obstruction
• Pathogenesis not well explained
• Definition varies

5. Gastric pacesetter potentials or slow waves
Cutaneous 3cmp EGG
waves
Fundus
Peristalti
c
wave
Corpus
3 cpm slow waves plus
action potentials

7. Etiology of Gastroparesis

8. Clinical Manifestations
•
•
•
•
Nausea
Vomiting
Bloating
Early Satiety
92%
84%
75%
60%

9. Gastroparesis Cardinal Symptom Index
(GCSI)
• Each parameter scored on 0-5 scale
1. Nausea
2. Retching
3. Vomiting
4. Stomach Fullness
5. Not able to finish normal-sized meal
6. Feeling excessively full after meals
7. Loss of appetite
8. Bloating (feeling like you need to loosen your
clothes)
9.Stomach or belly visibly larger

10. Grade

11. Post Surgical Gastroparesis

12. Incidence
• Peptic ulcer surgery with vagotomy
• Gastrectomy(0.4%-5%)
• Pancreatoduodenectomy(20-50%)
• Pancreatic cancer cryoablation(50-70%)
• Heart and lung transplantation

14. ISGPS suggested definition

15. • Absence of mechanical gastric outlet obstruction
• Gastric juice aspirate >800ml for more than 10
days
• No abnormalities in water, salt, electrolytes, or
acid–alkali balance
• Absence of underlying diseases
• No history of using suggestive agents

16. Pathogenesis-Surgical factors
• Multifactorial
• Denervation and resulting atony in gastric
remnant (Frederic et al.)
• Effect of vagotomy in proximal and distal
stomach
• Loss of vagal suppression on ectopic
intestinal pacemaker
• Associated procedures

17. Neuroendocrine and molecular factors
• Hyperglycemia
• Autonomic neuropathy
• Surgical stress-catecholamines
• Low motilin(absence of duodenum)
• Damage to ICC
• Hypothyrodism

18. Evaluation
• History
• Abdominal distention, Succussion
splash
• Clues to other etiologies
• Lab Tests

19. Evaluation
• EGD or Barium study
– Rule out gastric outlet obstruction

20. Evaluation
• Gastric Scintigraphy
– Gold standard
– 99M Tc Sulfur colloid bound to solid food
– Lack of standard criteria between institutions
• T1/2 or time intervals
• Different diagnostic criteria determined at each
institution
– Delay of 2 SD vs. 1.5 SD vs. 1 SD
• Different Meals
• Different patient positions

21. Gastric scintigraphy
Wu D J Y et al. BMJ Case Reports
2009;2009:bcr.06.2009.1986
©2009 by BMJ Publishing Group Ltd

22. Problems with Scintigraphy
• Radiation exposure
• Expensive
• Lack of standardization
–
–
–
–
differences in meals used
patient positioning
frequency and duration of imaging
Differences in quantitative data reported
• T1/2, rate of emptying, retention at different time points
• Lack of normal values

23. Wireless Motility capsule

24. WMC
1. Gastric emptying time
2. Small bowel transit time
3. Colonic transit time
4. Whole gut transit time
5. Amplitude of distal antral and duodenojejunal
contractions
6. Amplitude of phasic contractions of colon
7. Intragastric acidity

25. Breath test
•
13C-labelled
octanoate incorporated in a
solid meal
• Metabolised to 13C02
• 13C-spirulina

26. Complementary modalities
• Antroduodenal Manometry
• Electrogastrography

27. Treatment
• Correct fluid, electrolyte, and nutritional
deficiencies;
• Identify and rectify the underlying cause
of gastroparesis;
• Reduce symptoms-Ryle’s tube

28. Dietary Recommendation
• Increasing liquid nutrient content of the
meal
• Minimized fats and fiber intake
• Restricted meal size
• Alcohol to be avoided

29. Prokinetic Agents
• Enhance antral contractility
• Correct gastric dysrhythmias
• Improve antroduodenal coordination

31. Metoclopramide
• Antiemetic effect: D2,5-HT3
antagonism
• Prokinetic effect: +Ach release
• 5-HT4 receptor agonist
– Increase LES pressure/fundic tone
– Increase antral contractions

32. • Prokinetic effect limited to proximal GIT
• Effective for short term treatment
• Parenteral form available
• Nine trials
Pa rkman HP, Ha s l e r WL, F i s h e r RS . Ame r i c a n
Gastroenterological Association technical review on the
diagnosis and treatment of gastroparesis. Gastroenterology
2004; 127: 1592-1622

34. Erythromycin
• Gastroduodenal receptors of motilin
• + Antral contractility, Premature phase
III MMC
• Parenteral-most effective
• Narrow therapeutic window

36. Domperidone
– Benzimidazole derivative
– Dopamine 2 antagonist
– Promotility effect in upper GI tract
– Doesn’t cross blood-brain barrier
• Fewer central side effects
– Hyperprolactimemia, breast
engorgement, galactorrhea

38. Levosulpiride
• Selective D2 blocker, moderate 5HT4
agonist
• Superior than placebo
• Superior to Domperidone and
Metoclopramide in functional dyspepsia
Mansi C, Savarino V, Vigneri S, et al. Gastrokinetic effects of levosulpiride
in dyspeptic patients with diabetic gastroparesis.Am J Gastroenterol
1995; 90: 1989±93.

40. Antiemetic Agents
• May be needed for additional nausea
relief
• Role in gastroparesis not well
established

41. Botulinum Toxin
• Intrapyloric injection
Gastric emptying(decreased release of
excitatory transmitter)
• No controlled study

42. Refractory Gastroparesis
• Combination therapy
• Gastrostomy/Jejunostomy
• Gastric electric stimulation
Potentiate intrinsic slow waves
and phase III contractions

44. Surgical options
• In retractable cases as last resort
• Subtotal or completion gastrectomy
• Small uncontrolled series
• Forstner-Barthell et al: Largest series
 60 patients
 40 symptomatic improvements
• No definite winner

47. Take Home Message

48. • Etiology and pathogenesis not well explained
• Diet and lifestyle alterations, prokinetics and
anti-nausea medications are the mainstay of
therapy
• Novel medications and device are currently
being studied and offer promise
• Evidence based investigation required