Ever feel like you are nine-months pregnant after eating? Or does the feeling of eating make you nauseated and you are not able to keep anything down?
If that is the case, you may have a condition called gastroparesis.
What is gastroparesis?
The function of our stomach is to grind food into its lowest particle allowing passage into the small intestine, where the absorption of nutrients happens. The time frame to do that can vary from person-to-person but the vast majority 90-95% of the contents should be out of the stomach within four hours. If more than that stays due to poor motility of the stomach, the food can ferment and you will get the feeling of fullness and nausea. That problem with the motility of the stomach is called gastroparesis.
Causes of Gastroparesis
There are a lot of different theories for why physiologically gastroparesis occurs. The most common seems to be the loss of the pacemaker cells in the stomach, called the interstitial cells of cajal. These cells pump the stomach, similar to the rhythm of the heart, allowing food to pass. When someone develops gastroparesis, these cells are impaired in some way, leading to poor motility of the stomach.
Why people get this impairment can be a mystery. Some get it from other conditions such as diabetes, neurological disorders, or medications.
The most common cause, however, is that we just don’t know – some people just get gastroparesis and it is not clear why. This is termed idiopathic gastroparesis.
How do you know if you have gastroparesis
Some of the more common symptoms of gastroparesis include epigastric pain or discomfort, nausea, vomiting, bloating, getting full quickly, all which tend to worsen by eating.
The difficulty with those symptoms, however, is that it can be similar to other gastrointestinal problems including irritable bowel syndrome , dyspepsia, and gastrointestinal obstruction. It can be very hard to tease out what is what because of the similarity of symptoms – someone can have more than one condition.
My approach to diagnosing gastroparesis
One of the things we as gastroenterologists must rule out in gastroparesis is whether there is any obstruction within the stomach or small intestine. This typically includes evaluation with an upper endoscopy. Once that has been excluded, the gold standard for diagnosis is called the gastric emptying study.
This is a radiological exam in which you eat a low-fat egg-white meal with images taken at 0, 1, 2 and 4 hours after ingestion. You have to be off of certain medications that can promote gastroparesis (typically one week prior to the study).
There are different ways to do this test. Some centers perform a 90 minute study, others do a 2-hour study, while other centers do a 4-hour test.
If you’ve been diagnosed with gastroparesis on a study less than a 4-hour test, it is most likely an INACCURATE study.
The most accurate test for gastroparesis, with 100% since sensitivity and 70% specificity, is a 4-hour emptying study. This is a test I always use and it is the current gold standard.
How gastroparesis be treated
There are a lot of different ways to treat gastroparesis depending on what works best for each of individual. Here is my approach:
The most frequent and most common method of treatment is dietary modifications. You have to change your approach to eating. I call this method “grazing like a sheep”. It is small frequent meals, 5-6 times per day that are both low in fat (less than 40 g per day) and low in fiber.
In addition, liquid calories supplementation like Ensure(™) or Boost(™) can help out with nutrition. A good number of patients can treat their gastroparesis with this alone.
There are certain medical treatments which can help out with gastroparesis. This can be used in combination with dietary modifications.
Reglan is one of the most commonly used and feared medications for gastroparesis. This works by enhancing the contractions of the stomach and allowing coordination between the stomach and small intestine. It can be given both as a tablet or liquid formulation.
One of the most common side effects with Reglan are neurological including Parkinson’s syndrome (slowed walking or motor function, slow speech) and a condition called tardive dyskinesia. Additionally your heart rhythm can be prolonged.
This all sounds very scary and I can understand why people are concerned about taking these medications. However most patients, under a doctor’s supervision and at low doses, can effectively treat gastroparesis with Reglan in a safe manner.
Typically you want to start off with a very low-dose, preferably liquid formulation, with the goal of using this for a certain amount of time with a drug holiday in between usage. Using it in this manner can effectively treat gastroparesis safely.
Currently there is a prototype nasal spray application of reglan for gastroparesis. The nasal route allows better passage into the gastrointestinal tract, bypassing the gut. The spray seems to help out in female patients with gastroparesis only. While an early study, it seems to be beneficial in a certain segment of gastroparesis patients.
Domperidone is another medication that has been used for gastroparesis and based on a randomized controlled trial has been shown to be extremely effective. Similar to Reglan, this also helps with stomach contraction and coordination between the stomach and small intestine.
Domperidone, however, is not approved in the United States due to risk of cardiac conditions. Despite that, it is a very effective treatment for gastroparesis.
Botox injection into the stomach has been tried and the results are mixed. The thought is that the stomach will spasm in patients with gastroparesis causing worsening of symptoms. When botox is injected, theoretically the botox will minimize the spasm allowing food to pass. Studies have shown, however, that botox therapy may not help in all patients with gastroparesis though individual patients can have different results.
Gastric pacemaker is a surgically placed device into the stomach that takes the place of the interstitial cells of cajal (the pacemaker cells of the stomach) to control the contractions or motility of stomach.
This can be effective in some patients, particularly diabetic gastroparesis, in terms of improving nausea and vomiting and quality of life. Currently it’s approved for chronic refractory nausea and vomiting or for diabetic gastroparesis, specifically those who fail medical therapy.
Gastric feeding tube
Some patients with severe gastroparesis and severe weight-loss can have a feeding tube to provide nutritional support. Typically it goes into the small intestine, bypassing the stomach.
A small subset of patients have to remove part of the stomach to relieve symptoms of gastroparesis. This is usually reserved for those who fail medical therapy and have life-threatening nutritional deficiencies.
In summary gastroparesis is a condition in which the motility of the stomach is impaired leading to symptoms of nausea, vomiting, distension, and getting full quicker. The gold standard of diagnosis is a 4-hour gastric emptying study. There are a variety of ways to treat gastroparesis, all depending on the severity of your symptoms.
If you are concerned you may have gastroparesis or if you have any other gastrointestinal problems, feel free to contact me for an appointment at my office (806)-761-074 or visit my website (sameerislam.com) for more information.
Sameer Islam, MD is a board-certified Gastroenterologist and Hepatologist. For an appointment feel free to contact his office appointment at (806)-761-0747. You can get more information from his webpage (www.sameerislam.com), Facebook (facebook.com/sameerislamd), Twitter (@sislamMD), or watch his videos on YouTube (youtube.com/sameerislammd).