Gastroparesis

Rarely, the impaired nerve supply of the lower oesophagus can affect the stomach, leading to delayed emptying of the stomach or gastroparesis. This may cause a sensation of being very full and bloated after eating. Delayed gastric emptying worsens reflux symptoms. Although this is rarely a major problem, mild forms probably occur in up to 30% of patients. If suspected, this is a secondary care/tertiary care diagnosis and management issue.

Symptoms

• Early satiety
• Postprandial fullness
• Nausea
• Vomiting
• Abdominal pain

Diagnosis

• Gastroscopy to rule out obstructive causes of symptoms
• Gastric emptying studies

Severity

Grade 1 (most TOFs). Mild symptoms only, weight and nutrition unaffected.

Grade 2 – Moderate. Manageable by medication.

Grade 3 – Severe. Not managed by medication. Weight and nutrition not managed by oral intake.                                               Frequent hospitalisations.

Treatment

1. Nutrition. A symptom and diet history are needed to determine if intervention is needed. Most may need to change meal size and frequency only. Frequent, small, low-fibre, low-fat meals are advised, and alcohol and carbonated drinks discouraged. Liquid nutrients are also encouraged. If they are not eating enough calories to maintain weight, they are at risk of nutritional deficiencies including A, B₁, B₂, B₃, B₆, B₁₂, C, D, folate and minerals. Weight should be monitored. It is essential to have a dietician experienced in gastroparesis involved from first diagnosis.
2. Prokinetic agents. These improve gastric motility and gastric emptying times. These include metaclopramide, domperidone, erythromycin and azithromycin. Metaclopramide can also act as an anti-emetic.
3. Anti-emetics. Prochlorperazine is the most commonly prescribed in gastroparesis. Ondansetron is also used, both orally and intravenously during hospital admissions.
4. Endoscopic treatment with Botox injection to pylorus of stomach or dilatation of the pylorus with a balloon to 20–30mm.
5. Surgery to remove part or all of the stomach or widen the pylorus. This is only rarely necessary in severe cases.
6. Gastric pacemakers. These have been used in some centres to strengthen contractions and improve emptying but they remain experimental and any benefit remains unclear. (62,63)