How Is Drug-Refractory Gastroparesis Treated?

Yehuda Ringel, MD

Disclosures

January 18, 2012

Question:

I've seen a number of patients with drug-refractory gastroparesis. What are the treatment options for this condition?

Response from Yehuda Ringel, MD
Associate Professor, Division of Gastroenterology & Hepatology, University of North Carolina, Chapel Hill; Staff Physician, UNC Hospitals, Chapel Hill, North Carolina

Gastroparesis is characterized by delayed gastric emptying in absence of mechanical obstruction of the stomach or distal parts of the gastrointestinal (GI) tract. The presenting clinical symptoms include postprandial fullness and early satiety, nausea, vomiting, and bloating. Community-based epidemiologic data indicate a cumulative incidence of gastroparesis of 5.2% in type 1 diabetes, 1% in type 2 diabetes, and 0.2% in nondiabetic controls.[1] Commonly used medications for treatment of gastroparesis include: antiemetics (5-HT3 receptor antagonists, dopamine antagonists, antihistamines, and cannabinoids), prokinetics (dopamine antagonists and 5-HT4 agonists), and nonnarcotic pain relief medications.

The management of patients with gastroparesis who do not respond to medications should be focused on maintaining adequate hydration including electrolytes, acid-base balance, and nutrition; glycemic control in patients with diabetes; symptomatic relief; avoidance of contributing factors (eg, narcotic medications, uncontrolled diabetes); and improving gastric functions.

Early reports of several open trials suggesting a beneficial effect of intrapyloric botulinum toxin injection in patients with gastroparesis have led to increased use of this treatment in patients with intractable symptoms. However, recent randomized controlled trials revealed no efficacy of this intervention in improving gastric emptying or relieving gastroparesis-related symptoms in these patients.[2,3] Thus, currently, intrapyloric botulinum toxin injection has no role in the treatment of patients with gastroparesis.

In patients with significant gastrodoudenal dysmotility, endoscopic or surgically placed venting gastrostomy, jejunostomy, or both can significantly reduce the rate of hospitalization rate and improve nutritional status,[4] although the data on the long-term outcome of these interventions are limited.

Gastric electrical stimulation (GES) therapy uses high-frequency, low-energy electrical current to stimulate the nerves of the stomach and relieve the symptoms of gastroparesis. The device, Enterra® Therapy (Medtronic, Inc.; Minneapolis, Minnesota) was approved in 1999 by the US Food and Drug Administration as a humanitarian-use device for the treatment of patients with chronic, intractable (drug-refractory) nausea and vomiting secondary to gastroparesis of diabetic or idiopathic origin.[5] The approval followed a double-blind, crossover design study that reported improvement of weekly vomiting frequency and other GI symptoms and quality of life in 33 patients with diabetes and idiopathic gastroparesis.[6] It should be noted, however, that this study found no evidence of benefit in the subanalysis of the idiopathic gastroparesis subgroup. A recent metaanalysis summarized the results of 13 reported clinical studies using the GES device between January 1992 and August 2008. Although 12 of these studies were uncontrolled and used a range of clinical outcomes, overall the results show substantial benefits for GES in the treatment of gastroparesis.[7] In addition, a recent preliminary report of a multicenter, randomized, controlled study of 55 patients with diabetic gastroparesis showed significant lower weekly vomiting frequency after 12 months of unblinded ("on") treatment, with accompanying improvement in other gastroparesis-related symptoms and faster gastric emptying, despite no significant difference in weekly vomiting frequency between "on" and "off" periods during the initial 1-month crossover period.[8]

Finally, surgical intervention (eg, subtotal gastrectomy, gastrojejunostomy) should be reserved for patients with gastroparesis who do not respond to more conservative treatments. We suggest referring patients to tertiary referral centers before making a decision on gastric surgery. Carefully selected patients may benefit and experience relief of symptoms and improvement in quality of life.[9] However, the risks and benefits of these procedures have to be weighed on an individual basis.

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