Treatment

Ms DL was started on domperidone (prokinetics) and erythromycin (antibiotic). After 10 months, the episodes returned despite medical treatment. She then had a gastric pacemaker inserted, which only seemed to give benefit for six months. Ms DL recently spent weeks in hospital being treated with anti-nausea medication and intravenous fluids. Unfortunately, there was no way to improve the result with the pacemaker so she was given the option of Botox injections; however, the relief in symptoms after this was very short. After almost two years of suffering, Ms DL underwent a sleeve gastrectomy. (See medical explanations below).

• Prokinetics are drugs that improve the contraction of the stomach muscles, and move food through to the small intestine more effectively.
  • Metoclopromide is the active ingredient in Maxalon and Clopamom. This should be taken 20-30 minutes before meals. It helps reduce nausea and vomiting. Although it is approved for gastroparesis, it may have side effects, such as tardive dyskinesia – a movement disorder which causes shaking.
  • Domperidone
• Erythromycin is an antibiotic. When it is prescribed chronically at low doses, it improves stomach muscle contractions. Unfortunately, it can also cause nausea and stomach cramps which limits its use in the gastroparesis patient.
• Anti-emetics are anti-nausea drugs.
  • Prochlorperazine (Stemetil) is useful when the patient is acutely ill, however, it has even more side effects with chronic use than metoclopramide.
• Antipsychotic drugs
  • Chlorpromazine (Largactil) has frequently been used in patients with severe, persistent hiccups. Its actions on muscle have also worked in the patient with gastroparesis with some degree of success.
• Botulinum toxin is used when a gastroenterologist injects Botox directly into the pylorus (the valve between the stomach and duodenum involved in the rate of gastric emptying) using an endoscope. This relaxes the valve, keeping it open for longer periods allowing food to pass through. The results of Botox are quite variable; some patients have relief of their symptoms for months, while others find no improvement.
• Gastric pacemaker is a neurostimulator device which can be surgically implanted. This is normally done in patients with symptoms not responding to medication and diet changes. The battery-operated device has electrodes that are inserted into the stomach muscle wall. This then sends signals at regular intervals to stimulate the stomach muscle.   Studies have found that sending pulses that have a higher frequency than normal gastric contraction improves nausea and vomiting more effectively. However, more work needs to be done to refine this treatment for patients.
• Jejenostomy is a feeding tube which is placed through the abdominal wall directly into the jejunum (the second section of the small intestine). Special, balanced liquid food can then be given to the patient. It is commonly used in a malnourished, dehydrated patient.
• Surgery
  • Sleeve gastrectomy is a near total gastrectomy performed via keyhole surgery.
  • Roux-en-Y gastric bypass is when a small pouch is made from the top of the stomach and is attached to a loop of jejunum.

In both these surgeries, by removing most of the functional stomach it is possible to relieve symptoms of nausea and vomiting. Patients must be well-prepared, even though the dietary changes required are essentially the same as they should be following: small regular meals (see info on diet below).

Surgery is the treatment of last resort, but in my patient, this was life-changing. In the months post-surgery, she has had fewer and fewer episodes of vomiting. Generally, her symptoms have declined and her quality of life has improved incredibly.

Gastroparesis and diabetes

There is no doubt a vicious cycle exists when diabetes and gastroparesis occur together; high blood glucose directly slows down gastric emptying. Poor diabetes control for more than 10 years increases the risk of damage to the autonomic nervous system. The autonomic nerves control the automatic functions of the body, such as heart beat, blood pressure and gastric emptying.   The erratic emptying of food into the small intestine makes timing of insulin doses very difficult, and patients often swing from high to low blood glucose levels. It may be necessary to change the insulin regimen to get better control, and frequent blood glucose testing is vital.

Gastroparesis severely impacts a patient’s quality of life. Most patients with gastroparesis will respond to dietary changes, prokinetics and erythromycin.   However, for those that don’t, it is important to pursue more invasive treatment until relief of symptoms is achieved.