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Patients with Symptoms of Delayed Gastric Emptying Have a High Prevalence of Oesophageal Dysmotility, Irrespective of Scintigraphic Evidence of Gastroparesis

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Patients with Symptoms of Delayed Gastric Emptying Have a High Prevalence of Oesophageal Dysmotility, Irrespective of Scintigraphic Evidence of Gastroparesis BMJ Open Gastroenterol: first published as 10.1136/bmjgast-2017-000169 on 14 September 2017. Downloaded from Gastrointestinal motility Patients with symptoms of delayed gastric emptying have a high prevalence of oesophageal dysmotility, irrespective of scintigraphic evidence of gastroparesis George Triadafilopoulos, Linda Nguyen, John O Clarke To cite: Triadafilopoulos G, ABSTRACT Summary box Nguyen L, Clarke JO. Patients Background Patients with symptoms suggestive of with symptoms of delayed gastroparesis exhibit several symptoms, such as epigastric What is already known about this subject? gastric emptying have a high pain, postprandial fullness, bloating and regurgitation. prevalence of oesophageal It is uncertain if such symptoms reflect underlying ► Patients with epigastric pain, postprandial fullness, dysmotility, irrespective of bloating and regurgitation may have gastroparesis. scintigraphic evidence of oesophageal motor disorder. Aims To examine whether patients with epigastric ► Similar symptoms may be caused by oesophageal gastroparesis. BMJ Open Gastro motility disorder. 2017;4:e000169. doi:10.1136/ pain and postprandial distress syndrome suggestive Abnormal oesophageal acid exposure may also bmjgast-2017-000169 of functional dyspepsia and/or gastroparesis also have ► concomitant oesophageal motility abnormalities and, if play a role. Received 8 August 2017 so, whether there are any associations between these What are the new findings? by copyright. Revised 25 August 2017 disturbances. Accepted 28 August 2017 ► Patients with symptoms suggestive of gastric Methods In this retrospective cohort study, consecutive neuromuscular dysfunction have a high patients with functional gastrointestinal symptoms prevalenceof oesophageal dysmotility. suggestive of gastric neuromuscular dysfunction ► Oesophageal dysmotility occurs irrespective of the (gastroparesis or functional dyspepsia) underwent clinical degree of gastric emptying delay. assessment, gastric scintigraphy, oesophageal high- ► There is no relationship between oesophageal resolution manometry and ambulatory pH monitoring symptoms and motor or oesophageal pH using standard protocols. abnormalities. Results We studied 61 patients with various functional upper gastrointestinal symptoms who underwent gastric How might it impact on clinical practice in the scintigraphy, oesophageal high-resolution manometry and foreseeable future? http://bmjopengastro.bmj.com/ ambulatory pH monitoring. Forty-four patients exhibited ► High resolution oesophageal manometry should gastroparesis by gastric scintigraphy. Oesophageal be considered in patients with epigastric pain and motility disorders were found in 68% and 42% of patients postprandial distress syndromes. with or without scintigraphic evidence of gastroparesis ► If found to be present in such patients, oesophageal respectively, suggesting of overlapping gastric and dysmotility may contribute to symptoms. oesophageal neuromuscular disorder. Forty-three per cent ► Concomitant therapy for both gastric and of patients with gastroparesis had abnormal oesophageal oesophageal dysfunction may improve outcomes. acid exposure with mean % pH <4.0 of 7.5 in contrast to 38% of those symptomatic controls with normal gastric emptying, with mean %pH <4.0 of 5.4 (NS). Symptoms of epigastric pain, heartburn/regurgitation, bloating, nausea, manometry and pH monitoring are non-invasive and on October 1, 2021 by guest. Protected vomiting, dysphagia, belching and weight loss could potentially useful in the assessment and management of these patients. Stanford Multidimensional not distinguish patients with or without gastroparesis, Program for Innovationand although weight loss was significantly more prevalent and Research in the Esophagus severe (p<0.002) in patients with gastroparesis. There INTRODUCTION (S-MPIRE), Division was no relationship between oesophageal symptoms and Gastroparesis (GP) is a disorder charac- of Gastroenterology motor or pH abnormalities in either groups. andHepatology, Stanford Conclusions Irrespective of gastric emptying delay by terised by symptoms of and evidence for University School of Medicine, scintigraphy, patients with symptoms suggestive of gastric gastric retention in the absence of mechan- Stanford, CA 94305, USA neuromuscular dysfunction have a high prevalence of ical obstruction; its key symptoms include Correspondence to oesophageal motor disorder and pathological oesophageal postprandial fullness (early satiety), nausea, Dr George Triadafilopoulos; acid exposure that may contribute to their symptoms vomiting and bloating. Gastroparesis may vagt@ stanford. edu and may require therapy. High-resolution oesophageal result from autonomic (vagal) neuropathy, Triadafilopoulos G,et al . BMJ Open Gastro 2017;4:e000169. doi:10.1136/bmjgast-2017-000169 1 BMJ Open Gastroenterol: first published as 10.1136/bmjgast-2017-000169 on 14 September 2017. Downloaded from Open Access intrinsic neuropathy affecting excitatory and inhibi- and pH, among others). Patients were recruited through tory intrinsic nerves or the interstitial cells of Cajal, or a review of the electronic medical records, using Interna- a combination of extrinsic and intrinsic neuropathic or tional Classification of Diseases (ICD-10) code K31.84 for myopathic disorders.1 Other pathophysiological mech- gastroparesis and K30 for functional dyspepsia. Inclusion anisms, such as hypersensitivity or impaired accommo- criteria: On presentation, all patients were symptomatic dation, may also underlie symptoms in patients with with upper abdominal complaints that were recorded gastroparesis.2 Although the true prevalence of gastropa- on questioning and formal questionnaire-based assess- resis is unknown, it affects mostly women and impacts ment. To meet entry criteria, patients had to have one significantly on quality of life. Diabetes mellitus is the or more upper abdominal symptoms suggestive of gastric most common predisposing condition associated with neuromuscular dysfunction (gastroparesis or functional gastroparesis. Idiopathic and postsurgical gastroparesis dyspepsia), such as epigastric pain, postprandial bloating, are also leading aetiologies.3 nausea, vomiting, of at least a 2-month duration, a scin- Functional dyspepsia (FD) is characterised by similar tigraphic gastric emptying study and no gastric outlet symptoms as gastroparesis, and it may reflect either obstruction by endoscopy. Further, they had to have underlying delayed or accelerated gastric emptying, undergone a high-resolution oesophageal manometry impaired gastric accommodation and/or gastro-duo- and ambulatory pH monitoring. A detailed initial history denal hypersensitivity to food or distension.4 Data suggest and physical was conducted to exclude any other plausible that approximately 30% of patients with FD have delayed explanation for the patients’ symptoms, and additional gastric emptying when tested, although this may not be tests (eg, biopsies, biliary imaging, and contrast studies) the only mechanism at play nor necessarily responsible were ordered as indicated for diagnosis (see study flow for symptom pathogenesis.5 Two categories of functional in figure 1). Exclusion criteria: Patients <18 years, those dyspepsia are recognised: epigastric pain syndrome with known obstructive oesophageal or gastric disease by (EPS) and postprandial distress syndrome (PDS) with the endoscopy, those with systemic illnesses, such as sclero- latter having a similar clinical phenotype to idiopathic derma, or neurological conditions, such as Parkinson’s gastroparesis.6 In clinical practice, it is not uncommon disease. On presentation and during evaluation, none of to encounter patients with FD and symptoms suggestive the patients were receiving medication affecting gastric of gastric emptying delay, many of them with overlap- motility. Of note, the study, although community-based, by copyright. ping oesophageal symptoms, such as acid regurgitation was on a referral population to a gastroenterology prac- and dysphagia raising the possibility of an underlying tice with emphasis on motility disorders. oesophageal dysmotility. Indeed, GP has been noted to Questionnaires: To qualify for inclusion into the study, be present in 10% of patients with gastro-oesophageal all patients had to be symptomatic for epigastric pain, reflux disease (GERD), contributing to symptom severity postprandial bloating, nausea, or vomiting on a simple and treatment refractoriness.7 It is unclear whether there and previously validated general questionnaire. In this is an association between GP and refractory GERD.8 questionnaire, these and other symptoms were graded The aim of this study was to examine whether patients with scores for epigastric pain, regurgitation, postpran- with gastric neuromuscular dysfunction, such as epigas- dial bloating, nausea, vomiting, dysphagia, belching tric pain and postprandial distress syndrome suggestive and weight loss (0=no symptom, 1=mild symptom, http://bmjopengastro.bmj.com/ of FD and delayed gastric emptying, also have concom- 2=moderate symptom, and 3=severe symptom), occur- itant oesophageal motility abnormalities and, if so, ring at various frequencies (once a week=0, 2 to 6 times a whether there are any associations between these distur- week=1, 7 to 15 times a week=2, and more than 15 times bances. We hypothesised that patients with scintigraphic a week=3).9 The clinical severity of gastroparesis was evidence of GP would have a high probability of oesopha- graded globally into three
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