Gastroparesis Diagnosis and Treatment <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> Gastroparesis Diagnosis and Treatment Bill Richards, MD FACS Professor and Chair Surgery University of South Alabama College of Medicine

Anatomical and Functional regions of the Stomach

Migrating Motor Complex

Etiology of Gastroparesis Diabetes-related Metabolic hyper-glycemia, hypo-kalemia, hypermagnesemia Hypo-pituitarism, hypo-adrenalism, hypo-thyroidism Chronic renal failure Portal hypertension Intra-abdominal malignancy Infectious: H. pylori., EBV Rheumatological: Systemic sclerosis, SLE, Myotonic dystrophies Central Nervous System disorders (Parkinson’s disease, multiple sclerosis) Peripheral Nervous System disorders (amyloid neuropathy, Guillain-Barre, primary dysautonomia) Psychiatric disorders (anorexia nervosa, rumination syndrome)

Surgery Related Etiology of Gastroparesis Vagotomy, Duodenectomy Mechanical Obstruction Partial

Drugs that delay Gastric Emptying Alcohol Aluminium hydroxide antacids Atropine beta-Agonists Calcium channel blockers Diphenhydramine L-Dopa Lithium Ondansetron Opiates Phenothiazines Tricyclic anti-depressants

Gastric Inhibitory Hormones Stimulation Site of Secretion Other Actions Cholecystokinin fat and protein in small bowel Duodenum jejunum Gastric relaxation, sensation of fullness Glucagon Hypoglycemia, amino acids, beta-adrenergic stimulation pancreas (alpha cells) Slows MMC Glucagon-like peptide-1 Increased glucose, fatty acids and amino acids Distal Small intestine and colon decreases appetite Peptide YY Terminal ileum and colon Secretin Acid, lipid or bile in duodenal lumen Duodenum (D Cells) Acts indirectly via inhibition of gastrin release Somatostatin Acidification of duodenal lumen Gastric antrum (D cells) Induces Fasting Small Intestinal activity

Gastric Stimulatory Hormones Table 1. Hormonal influences of gastric motility Stimulatory Hormone Stimulation Site of Secretion Other Actions Gastrin Gastric pH>3, vagus nerve, antral distention, protein, calcium, alcohol Gastric antrum (G cells) Inhibits small bowel and colonic motility Ghrelin Fasting Gastric fundus Stimulates hunger Motilin Acid and vagus nerve Stomach and duodenum (M Cells) Induces phase 3 MMC peristalsis

Anti-emetic agents Prochlorperazine Compazine Promethazine Tardive dyskinesia Promethazine 5-hydroxytryptamine receptor agonist (i.e. odansetron) Reduce dose with hepatic disease

Placebo and Botox improved symptoms and gastric emptying Botulinum Toxin A for the Treatment of Delayed Gastric Emptying Am J Gastro 103; 416-423, 2008 Within Group   Botulinum Toxin Placebo Improved (%)* 37.5% 56.3% % Gastric retention†  2 h -16.3+ 22.9 -10.8+ 20.6 Placebo and Botox improved symptoms and gastric emptying

Prokinetic agents Metoclopramide (reglan) Erythromycin Domperidone. Antral contractions Extrapyramidal symptoms Erythromycin Motolin agonist Induces phase III MMC Cardiac arrhythmias Domperidone. Not marketed in US Cisapride cardiac arrhythmias FDA removed from use

Enterra Neurostimulator

Predictive Factors for Clinical Improvement with Enterra Gastric Electric Stimulation Treatment for Refractory Gastroparesis Dig Dis Sci (2008) 53:2072–2078 Improved N=14 Same N=8 Worse N=6 Age 45 33 38 Female % 71% 100% % diabetic 50% 60% 33% Use narcotics 29% 75% Gastric emptying % retention at 4 H 72% 54%

Ileal Brake Ileal brake is most potent inhibitory feedback Companion brakes work in absence of ileal brake

Ileal Brake Fats in ileum trigger release of Peptide YY Peptide YY inhibits gastric emptying

Resectional Therapy Subtotal gastrectomy Roux-en-Y reconstruction Preop measurement of vitamin D, Thiamine, B-12, folate, iron