Treatment for Gastroparesis By Jennifer Katada R 2
Treatment for Gastroparesis By: Jennifer Katada R 2
Case Summary: A 47 y/o female w/ hx of GERD, C 5 -6 spondylolithesis, and recent hospitalization for intractable nausea, vomiting, and abdominal pain 2 weeks prior. EGD showing mild gastritis and CT ABD was wnl. She presented w/ abdominal pain, nausea, vomiting, diarrhea found to have idiopathic gastric paresis with abnormal gastric emptying study. She was treated with metoclopramide.
Clinical Question: P = Patient population In patients with idiopathic gastroparesis I = Intervention, prognostic factor, or exposure does treatment with erythromycin C = Comparison when compared to metoclopromide O = Outcomes improve gastric motility and symptoms. How I did the search / Article Pub Med – “idiopathic gastroparesis” “metoclopromide” and “erythromycin” Found article: “The relation between symptom improvement and gastric emptying in the treatment of diabetic and idiopathic gastroparesis” Am J Gastroenterol. 2013 Sep; 108(9): 1382 -91.
METHODS MEDLINE database search Studies included – diabetic and idiopathic gastroparesis Only controlled trials or trials with an established effective comparator looking at symptom improvement and gastric emptying were used 34 papers meeting criteria, but only 23 papers had recorded means for symptom improvement and gastric emptying Meta-regression was used % change in gastric emptying to % change in symptom improvement
Results Studies Metoclopramide N=6 Domperidone N=6 Cisaoride N =14 Erythromycin N=3 Botulinum toxin N=2 Levosulpiride N=3 No studies for Mitemcinal (ABT-229), TZP-101, azithromycin, prucalopride, tegaserod, and clonidine Symptoms improvement was logged in various ways including daily diary to Likert-scale-based assessment of symptom severity. ** Validated symptom assessment - The Gastroparesis Cardinal Symptom Index was only used in 2 studies **
Results Gastric emptying Scintigrapthy – 15 studies (2 hours); 3 studies (4 hours) 5 studies used various tests 4 studies used ultrasound 1 study used emptying of radiopaque markers End points for emptying included Time to complete evacuation Half emptying time Percent retention of meal Type of meal Liquid (only 1 study) Solid/liquid Solid
Results All eligible studies compared Gastric Emptying and Symptom Improvement Positive association: Slope 0. 169 95% CI -0. 246 to 0. 584 P = 0. 4 Subgroup analysis also failed to show statistical significance.
Conclusions Relationship between symptoms and abnormal gastric emptying is still under debate Abnormal gastric emptying can be symptomatic and asymptomatic Confounders- impaired gastric accommodation and visceral hypersensitivity Tx with prokinetic drugs has been based on older studies with metoclopramide, domperidone, and erythromycin which showed these accelerated gastric emptying None of the studies included showed a significant correlation between emptying and symptoms
Limitations of the study Only 23 of total 36 studies were used due to incomplete data sets Heterogeneity between treatment, symptom improvement assessment, and modality for measuring gastric emptying
Summary / Application More studies are needed- and use of the standardized symptom reporting may improve the ability to find a correlation if one exists Important to note- that many of the medications not only have a prokinetic effect, they also are antiemetic properties which may improve symptoms but not gastric emptying There is no rational to retest gastric emptying after treatment as there is lack of correlation between gastric emptying and symptom improvement
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