For
other articles and previous issues click here.
August 9, 2004
The Other
Slow Food Movement
Treating Gastroparesis
By Victoria Shanta-Retelny, RD, LD
For the Record
Vol. 16, No. 16, Page 32
Get up to speed on the diagnosis and treatment
of this slow-motion, stomach-emptying syndrome.
Imagine a world with no movement, where time stands
still or is halted like a slow-motion scene in a movie. That’s
what the world is like for people suffering from gastroparesis.
As the term denotes—gastro means stomach and paresis means
paralysis—this condition is one of halted or delayed gastric
emptying. The lack of motility happens when nerves to the stomach
are damaged or stop working. Since the vagus nerve controls the
movement of food through the digestive tract, if it’s damaged
for any reason, the muscles of the stomach and intestines do not
work normally and the movement of food is slowed or stopped.(1)
This gut dysmotility can be a serious threat to nutritional health
and long-term well-being.
To see how this condition is manifested in the body,
think about the anatomy and physiology of the stomach cavity. Similar
to the heart, the stomach cavity has a pacemaker where an electrical
wave originates. This pacemaker is powered in the fundus (the upper
portion of the stomach). The wave sweeps across the organ to the
lower cavity, the antrum, causing it to contract, grind, and expel
food into the duodenum. The normal rate of contraction is roughly
three times per minute—much slower than the heart(2)—but
nevertheless just as efficient at getting the job done.
In gastroparesis, the pacemaker’s rhythm is
severely delayed, causing fewer contractions; the food lays in the
stomach, relying on acid and digestive enzymes to break it down
and gravity to empty the stomach.(2) If food lingers too long in
the stomach, it can cause problems such as bacterial overgrowth
from the fermentation of food. Also, the food can harden into solid
masses called bezoars that may cause nausea, vomiting, and obstruction
in the stomach. These can be dangerous if they block the passage
of food into the small intestine.(3)
What Causes Vagus Nerve Disruption?
The exact cause of the nerve stimulation disruption is unknown,
but there are some strong links to why this delayed gastric emptying
occurs. The medical term for one type of this condition is Gastroparesis
diabeticorum since the most commonly cited cause of gastroparesis
is diabetes. At least 20% of people with type 1 diabetes develop
gastroparesis.(4) It’s possible, but much less common, in
people with type 2 diabetes. The rationale behind the diabetes link
is that prolonged high blood sugars can damage the vagus nerve,
which controls the motor function in the upper gastrointestinal
(GI) tract. High blood glucose causes chemical changes in nerves
and damages the blood vessels that carry oxygen and nutrients to
the nerves.(3)
Up to 30% of individuals with gastroparesis are
idiopathic, meaning there is no identifiable cause. Some of these
cases may be due to an acute viral infection.(5) Besides diabetes,
medical literature points to other known risk factors such as systemic
sclerosis, previous vagotomy (intentional nerve cutting for surgery
on peptic ulcer disease), previous gastrectomy, visceral neuropathy,
and use of anticholinergic medication (antispasmodics).(2)
Common Symptoms
There are a number of abdominal complaints, including feeling full
after only a few bites of food, bloating, excessive belching, and
nausea.(1) “There may be vomiting, heartburn, or regurgitation
of stomach fluid into the mouth,” according to Bethany Doerfler,
MS, RD, LD, a dietitian at Northwestern Memorial Hospital Wellness
Institute in Chicago. Doerfler speaks from personal experience;
she has lived with gastroparesis for several years. The severity
of cases can differ, Doerfler points out: “Some people have
complete dysmotility where others can have moderate delayed gastric
emptying.”
In patients with diabetes, symptoms worsen with
poor glucose control. The degree of dysmotility matters as patients
with serious delays in gastric emptying frequently experience erratic
blood sugars. Hyperglycemia has been shown to slow gastric emptying
whereas hypoglycemia may accelerate it; thus, blood glucose concentrations
may also influence symptoms.(4)
The management of diabetic gastroparesis often represents
a significant clinical challenge in which the nutritional maintenance
is pivotal. Gastric emptying is delayed in 30% to 50% of patients
with long-standing type 1 or type 2 diabetes. Upper GI symptoms
also occur frequently.(6) It is this unpredictability in stomach
emptying that causes excursions in blood glucose levels and creates
health complications down the road.
Diagnosis
Recent medical advances have allowed GI specialists to make a definitive
diagnosis of gastroparesis more quickly. However, there are still
some contradictory beliefs in the medical community about what constitutes
an exact diagnosis for this condition. One stance is that if there
is no retained food matter in the stomach upon analysis, it is not
gastroparesis—but that’s not necessarily always true.
According to Doerfler, “In my case, I did not have retained
food in my stomach when my doctor performed an upper endoscopy or
esophagogastroduodenoscopy [EGD],” says Doerfler, “but
upon further probing with a gastric emptying scan, the diagnosis
was confirmed.”
Radioisotope Gastric Emptying
Scan
Since gastroparesis is a “functional” disorder, diagnostic
tests cannot only view the stomach (eg, x-ray); they must specifically
test its mechanics. One of the most common methods is a radioisotope
gastric emptying scan. This test requires eating a food containing
a safe, small dosage of a radioisotope. After the food is eaten,
the patient lies under a machine that detects the radioisotope and
shows an image of the food and how quickly it leaves the stomach.
Gastroparesis is diagnosed if more than one-half of the food remains
in the stomach after two hours.(1) It is important to note that
since the stomach may empty properly one day and not the next, most
tests are repeated to make an accurate diagnosis.
Barium Tests for Gastroparesis
Other diagnostic tests include barium x-ray, which involves drinking
a thick liquid after a 12-hour fast. This barium liquid coats the
stomach to reveal its contents. In a normally functioning stomach,
there would be no contents left after 12 hours, but if there is
food lingering in the cavity, a gastroparesis diagnosis is likely.
Another barium-related test that can detect emptying problems that
may not show up with the barium x-ray involves eating a barium beefsteak
meal. Once the meal is ingested, a radiologist can watch the course
of the food as it’s digested. This test is useful for detecting
diabetes-related gastroparesis because oftentimes liquid is digested
normally in this population, but solid foods are severely delayed.
EGD
Although EGD results are often normal in people with gastroparesis,
it is still used as a diagnostic tool. There should be no eating
or drinking for at least six hours before an EGD to ensure that
the stomach and duodenum are empty. (The timing is at the discretion
of the physician performing the EGD.) In this 20- to 30-minute procedure,
a small, lighted endoscope is swallowed and passed through the esophagus
into the stomach and duodenum. (A numbing agent is sprayed in the
throat to prevent gagging.) The endoscope casts an image and blows
air into the stomach to allow the physician to fully see the lining
of the upper GI tract. Through the scope, the physician can insert
instruments to extract tissue if a biopsy is needed.
Alternative Diagnostic Tests
Research to find innovative, less costly ways to identify gastroparesis
without exposing patients to low levels of ionizing radiation has
led to another means of diagnosis: the hydrogen breath test.
At the western regional meeting of the American
Federation for Medical Research in March 2001, data were presented
that looked at 12 healthy controls, 10 diabetic patients with confirmed
gastroparesis, and 10 diabetic patients without gastroparesis. All
patients were administered a baseline hydrogen breath test with
a QuinTron SC breath hydrogen analyzer. They were fed an evening
meal of hydrogen-producing food, such as potatoes and lactulose.
The next morning they took a breath test; both the control group
and those without gastroparesis scored the same—breath hydrogen
levels of less than 1 part per million. The group with gastroparesis
had breath hydrogen levels of 25 parts per million.(7)
Treatment Options
Treatment of both diabetic and idiopathic gastroparesis is difficult,
and the medications currently available often do not provide long-term,
substantial relief of symptoms for many patients.(7) Dietary recommendations
emphasize optimizing glycemic control for diabetics, eating small,
frequent meals, limiting intake of fiber,(8) restricting fat intake,(9)
and replacing solid food with liquid meals.(8)
Many dietitians educate patients on their “timing
of meals,” according to Valerie Peters, MS, RD, LD, a dietitian
in private practice in Dublin, Ga. Peters uses a multifaceted approach
of small, frequent meals throughout the day combined with prokinetics
medications, such as Reglan, and/or insulin or oral agents to control
blood sugars, if appropriate.
When treating patients with gastroparesis, keep
in mind the patients’ activity levels. Patients who are not
physically active may be at greater risk of consuming inadequate
diets than those who are active. Even though the causative factors
in diabetic vs. idiopathic gastroparesis differ, patients with both
conditions have similar gastrointestinal symptoms, which appear
to exert an adverse effect on dietary adequacy.(10)
Treatments for gastroparesis include eating small
meals throughout the day and avoiding fatty foods and other difficult-to-digest
foods, such as legumes, lentils, and citrus fruits. Limiting or
avoiding alcohol and coffee is often recommended. If gastroparesis
is a complication of diabetes, insulin therapy adjustment may be
needed to better control blood glucose levels.(4)
Pharmacotherapy Treatments
Along with adequate medical nutrition therapy, the use of prokinetic
medications has been proven effective for treating gastroparesis.
Here are some current medications being prescribed for treatment:
• Reglan (Metochropropamide) works in the brain to relieve
nausea and vomiting and can work on the stomach muscle directly.
It does have side effects: 30% of users experience tremors, agitations,
twitching, or stiffness. This drug is contraindicated for patients
with Parkinson’s disease.
• Propulsid (Cisapride) has been used to relieve symptoms,
but close medical supervision is needed secondary to reports of
heart rhythm problems. This medication should not be used in anyone
with significant heart disease, kidney and liver diseases, and/or
any condition causing electrolyte problems.
• Erythromycin in small doses can be effective for gastroparesis;
either tablet or liquid forms of this antibiotic are effective.
Liquid forms must be stored in the refrigerator.
• Zelnorm (tegaserod maleate) is traditionally used in the
treatment of irritable bowel syndrome with constipation (hard stools
or difficulty passing stools) as the main bowel problem. The FDA
recently updated risk information on labels to highlight this drug’s
contraindications. This prokinetic should not be used by patients
with frequent or current diarrhea, severe kidney or liver disease,
bowel obstruction or intestinal blockage, symptomatic gallbladder
disease, or abdominal adhesions causing pain and/or intestinal blockage.
Enterra Therapy: The New-Age
Stomach Pacemaker
Gastric electrical stimulation (GES), or Enterra therapy, a new
device to aid in the relief of gastroparesis, has been approved
by the FDA. This “stomach pacemaker” falls under a special
designation of Humanitarian Use Device. The one catch is that it
is difficult to access this technology because insurance companies
label Enterra therapy as “experimental.” Lobbying groups,
such as the Gastroparesis and Dysmotilities Association, are currently
petitioning the FDA for full approval of GES.
The bottom line in treating gastroparesis is recognizing
sign and symptoms in patients/clients. By taking action and putting
them in touch with a motility specialist (a gastroenterologist with
a subspecialty in motility disorders), a correct diagnosis will
be made sooner and improvements in quality of life can begin.
— Victoria Shanta-Retelny, RD, LD, is a
practicing dietitian at Northwestern Memorial Wellness Institute
in Chicago, a freelance food and nutrition writer, and a culinary
spokesperson.
References for this article are available upon request
by e-mailing edit@gvpub.com.
Medical Nutrition Therapy Recommendations for
Gastroparesis
• Eat small, frequent meals throughout the day.
• Avoid fatty, rich foods.
• Limit hard-to-digest foods (eg, high-fiber legumes, lentils,
and citrus fruits).
• If gastroparesis is severe, a liquid diet may be appropriate
until motility improves.
• Limit alcohol and caffeine use as these may trigger symptoms.
• Do not underestimate the power of exercise. Daily walks
before and/or after a meal are beneficial in increasing smooth muscle
motility.
Professional Interest Groups and Patient Resources
Gastroparesis Patient Association for Cures and Treatments
www.g-pact.org
This is an interactive Web site that allows patients to connect
with one another and share experiences, offers discount restaurant
cards, provides information about the Patient Awareness Liaison
Program sponsored by Medtronic, and maintains five toll-free numbers
for patients to call for support and answers to their questions.
Gastroparesis and Dysmotilities Association
www.gpda.net
This is a nonprofit organization dedicated to finding answers, increasing
awareness, and supporting research on gastroparesis and related
gastrointestinal motility disorders.
The American Motility Society
www.motilitysociety.org
This is a professional organization that serves as “a platform
for shaping the future of GI [gastrointestinal] motility”
with research, development, and networking opportunities.
Subscribe to For the
Record Magazine! |
