The Dilemmas of Gastroparesis
We’ve come a long way in being able to diagnose this,” says Kyle Packer, DO, about gastroparesis, also called gastric stasis, a rare stomach disorder in which food moves through the stomach too slowly.
The symptoms are straightforward but deceptive. “It has a pretty generic symptom profile,” Packer says, listing nausea, vomiting, reflux, bloating, abdominal pain, and dehydration. Since it mimics symptoms of gastritis, peptic ulcers, and reflux, it can be easy to misdiagnose. Abdominal bloating along with chronic nausea or other disease processes can be signal. “If they use those buzzwords together and they’re diabetic, I steer more towards gastroparesis first,” he says.
Around 57 percent of those with gastroparesis are diabetic. “It’s not that common of a condition, but in Alabama, unfortunately there is a large population of diabetic patients. So it’s more common than we think,” says Packer, a general surgeon at Walker Baptist Medical Center in Jasper with a fellowship in advanced gastrointestinal minimally invasive surgery.
The most common test for diagnoses, called gastric emptying scintigraphy, involves eating a special meal of an exact number of calories and grams of fat, usually scrambled eggs. Tagged with radiation at a radioactivity level equivalent to an hours walk in the sun, the food can then be monitored as it moves through the stomach and digestive system. “We monitor for couple of days on how much contrast moves through stomach,” Packer says. “If it’s slow emptying, then they meet the definition for gastroparesis.”
Other diagnostic tests exist, such as upper endoscopy or esophagogastoduodenoscopy (EGD). But Patrick has found it to be inconsistent, since some follow-up gastric emptying studies have come back negative. Radioactive capsules offer another diagnostic option. “They’re great for small bowel pathology, but they doesn’t show the motility of the muscles,” he says. “I put most of my faith in gastric emptying.”
About 50 percent of the gastric emptying tests turn out positive among Packer’s patients. “But I probably order more tests than most physicians because I see more patients with these symptoms,” he says. He is one of only three physicians in the Birmingham area who deal with this condition. Between 30 to 50 percent of his patients end up diagnosed with the gastroparesis.
The treatment begins with diet. Four to six smaller meals a day. Eating solid food in the morning and more blended, liquid intake toward evening to eliminate solids in the stomach at night. No high fat and fiber foods, because they’re hard to digest. Avoiding sugar spikes, such as with sugary drinks, because high blood sugar intensifies gastroparesis. Some patients cannot tolerate any solid food. Medications, such as Reglan (metoclopramide), can help with gastric motility, but have risks so they are generally used short-term and sporadically. Erythromycin induces forceful contractions, but is not well-tolerated by many gastroparesis patients and, as an antibiotic, there is the long-term risk of building up resistance to antibiotics.
More long-term relief can be found in surgical options. Packer uses the gastric neuro stimulator. A battery implanted under the skin of the abdomen connects to two leads attached to electrodes placed on the membrane lining of the stomach. The electrodes send impulses that stimulate muscle contractions to improve gastric emptying.
“The stimulator is a game changer,” Packer says. “It’s been around closer to 10 years, but there have been many advances, and improvements in the physics of the device, including updating the leads for reliability and improved battery life.”
One of his gastroparesis patients suffered nausea daily enduring two episodes of vomiting a day. She required multiple trips to the emergency department and hospitalization for IV fluids due to dehydration. “Two weeks ago, she had a gastric neuro stimulator put in, and she has complete resolution of her symptoms now,” Packer says.
The device allows a physician to adjust the rate, voltage, and duration of the impulses to suit the patient’s needs. Typically, patients start at a .1 second energy burst every five seconds. “If they’re doing better but have room for improvement, for example, then we can increase that to a one second burst for every five seconds,” Packer says. Higher numbers deplete the battery faster within three years, which requires a surgical intervention in the OR to replace. A fair number of his patients, though, remain on the low settings, giving them five to six years of use per battery.
“This is a great therapy we have, as long as we continue to advance the tech,” Packer says. “I hate having to put patients to sleep for this so often.”
Since no cure yet exists, the goal for Packer is to improve the patient’s quality of life by 70 to 80 percent. “Most get to 80 percent. They’re so happy because that means they may have been having eight episodes of nausea or be vomiting twice a day. Instead it’s one to two times a week,” he says. “This is all about getting people back to a normal routine in life.”
The symptoms are straightforward but deceptive. “It has a pretty generic symptom profile,” Packer says, listing nausea, vomiting, reflux, bloating, abdominal pain, and dehydration. Since it mimics symptoms of gastritis, peptic ulcers, and reflux, it can be easy to misdiagnose. Abdominal bloating along with chronic nausea or other disease processes can be signal. “If they use those buzzwords together and they’re diabetic, I steer more towards gastroparesis first,” he says.
Around 57 percent of those with gastroparesis are diabetic. “It’s not that common of a condition, but in Alabama, unfortunately there is a large population of diabetic patients. So it’s more common than we think,” says Packer, a general surgeon at Walker Baptist Medical Center in Jasper with a fellowship in advanced gastrointestinal minimally invasive surgery.
The most common test for diagnoses, called gastric emptying scintigraphy, involves eating a special meal of an exact number of calories and grams of fat, usually scrambled eggs. Tagged with radiation at a radioactivity level equivalent to an hours walk in the sun, the food can then be monitored as it moves through the stomach and digestive system. “We monitor for couple of days on how much contrast moves through stomach,” Packer says. “If it’s slow emptying, then they meet the definition for gastroparesis.”
Other diagnostic tests exist, such as upper endoscopy or esophagogastoduodenoscopy (EGD). But Patrick has found it to be inconsistent, since some follow-up gastric emptying studies have come back negative. Radioactive capsules offer another diagnostic option. “They’re great for small bowel pathology, but they doesn’t show the motility of the muscles,” he says. “I put most of my faith in gastric emptying.”
About 50 percent of the gastric emptying tests turn out positive among Packer’s patients. “But I probably order more tests than most physicians because I see more patients with these symptoms,” he says. He is one of only three physicians in the Birmingham area who deal with this condition. Between 30 to 50 percent of his patients end up diagnosed with the gastroparesis.
The treatment begins with diet. Four to six smaller meals a day. Eating solid food in the morning and more blended, liquid intake toward evening to eliminate solids in the stomach at night. No high fat and fiber foods, because they’re hard to digest. Avoiding sugar spikes, such as with sugary drinks, because high blood sugar intensifies gastroparesis. Some patients cannot tolerate any solid food. Medications, such as Reglan (metoclopramide), can help with gastric motility, but have risks so they are generally used short-term and sporadically. Erythromycin induces forceful contractions, but is not well-tolerated by many gastroparesis patients and, as an antibiotic, there is the long-term risk of building up resistance to antibiotics.
More long-term relief can be found in surgical options. Packer uses the gastric neuro stimulator. A battery implanted under the skin of the abdomen connects to two leads attached to electrodes placed on the membrane lining of the stomach. The electrodes send impulses that stimulate muscle contractions to improve gastric emptying.
“The stimulator is a game changer,” Packer says. “It’s been around closer to 10 years, but there have been many advances, and improvements in the physics of the device, including updating the leads for reliability and improved battery life.”
One of his gastroparesis patients suffered nausea daily enduring two episodes of vomiting a day. She required multiple trips to the emergency department and hospitalization for IV fluids due to dehydration. “Two weeks ago, she had a gastric neuro stimulator put in, and she has complete resolution of her symptoms now,” Packer says.
The device allows a physician to adjust the rate, voltage, and duration of the impulses to suit the patient’s needs. Typically, patients start at a .1 second energy burst every five seconds. “If they’re doing better but have room for improvement, for example, then we can increase that to a one second burst for every five seconds,” Packer says. Higher numbers deplete the battery faster within three years, which requires a surgical intervention in the OR to replace. A fair number of his patients, though, remain on the low settings, giving them five to six years of use per battery.
“This is a great therapy we have, as long as we continue to advance the tech,” Packer says. “I hate having to put patients to sleep for this so often.”
Since no cure yet exists, the goal for Packer is to improve the patient’s quality of life by 70 to 80 percent. “Most get to 80 percent. They’re so happy because that means they may have been having eight episodes of nausea or be vomiting twice a day. Instead it’s one to two times a week,” he says. “This is all about getting people back to a normal routine in life.”