1. Gastroparesis Diagnosis and Treatment
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Gastroparesis Diagnosis and Treatment
Bill Richards, MD FACS
Professor and Chair Surgery
University of South Alabama
College of Medicine

2. Anatomical and Functional regions of the Stomach

3. Migrating Motor Complex

4. 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)

5. Surgery Related Etiology of Gastroparesis
Vagotomy,
Duodenectomy
Mechanical Obstruction Partial

6. 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

7. 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

8. 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

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

10. Placebo and Botox improved symptoms and gastric emptying
Botulinum Toxin A for the Treatment of Delayed Gastric Emptying Am J Gastro 103; , 2008
Within Group
Botulinum Toxin
Placebo
Improved (%)*
37.5%
56.3%
% Gastric retention†
 2 h
Placebo and Botox improved symptoms and gastric emptying

11. 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

12. Enterra Neurostimulator

13. 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%

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

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

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