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Current Diagnosis and Treatment of Gastroparesis: a Systematic Literature Review

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Current Diagnosis and Treatment of Gastroparesis: a Systematic Literature Review DOI: https://doi.org/10.22516/25007440.561 Review article Current diagnosis and treatment of gastroparesis: A systematic literature review Viviana Mayor,1* Diego Aponte,2 Robin Prieto,3 Emmanuel Orjuela.4 Abstract OPEN ACCESS Normal gastric emptying reflects a coordinated effort between different Citation: regions of the stomach and the duodenum, and also an extrinsic modu- Mayor V, Aponte D, Prieto R, Orjuela E. Current diagnosis and treatment of gastroparesis: lation by the central nervous system and distal bowel factors. The main A systematic literature review . Rev Colomb Gastroenterol. 2020;35(4):471-484. https://doi. org/10.22516/25007440.561 events related to normal gastric emptying include relaxation of the fundus to accommodate food, antral contractions to triturate large food particles, ............................................................................ the opening of the pyloric sphincter to allow the release of food from the 1 Internist and professor, Clínica Versailles, Universidad Javeriana. Cali, Colombia. stomach, and anthropyloroduodenal coordination for motor relaxation. 2 Gastroenterology Service, Area Coordinator, Clínica Universitaria Colombia. Bogotá, Colombia. Gastric dysmotility includes delayed emptying of the stomach (gastropare- 3 Gastroenterologist, Clínica Universitaria Colombia. Bogotá, Colombia. sis), accelerated gastric emptying (dumping syndrome), and other motor 4 Medical doctor. Universidad Javeriana. Clínica Versalles. Cali, Colombia. dysfunctions, e.g., deterioration of the distending fundus, most often found *Correspondence: Viviana Mayor. in functional dyspepsia. The symptoms of gastroparesis are nonspecific [email protected] and may mimic other structural disorders. ............................................................................ Keywords Received: 07/05/20 Gastric emptying, Gastroparesis, Gastric dysmotility. Accepted: 16/09/20 INTRODUCTION vomiting, early satiety, anorexia, weight loss, and epigastric pain (1). Different diagnostic techniques and therapeutic Gastric emptying depends on the coordinated activity bet- approaches have been proposed over time. Therefore, this ween different areas of the stomach and the duodenum. systematic review aims to describe the current relevant lite- This process is extrinsically modulated by the central ner- rature on the different diagnostic options and therapeutic vous system (CNS) and by factors occurring in the distal approaches to gastroparesis. A summary of what is known intestine. Gastroparesis is a chronic symptomatic disorder to date about gastroparesis, with an emphasis on its etio- consisting of delayed gastric emptying without mechanical logy, pathophysiology, and current definitions is performed obstruction being present. Its main causes are of endo- prior to describing how the review was conducted and the crine, neurological and metabolic origin, and the most results retrieved. With that in mind, the findings retrieved frequent clinical entity is diabetic gastroparesis. Symptoms from the studies included in the review regarding contrast are variable and may overlap with other gastrointestinal radiography techniques, gastric emptying scintigraphy, diseases. Patients with gastroparesis suffer from nausea, drugs affecting gastric emptying, gastroparesis breath test, © 2020 Asociación Colombiana de Gastroenterología 471 electrogastrography, antroduodenal manometry, ultra- Table 1. Reversible causes of gastroparesis sonography, magnetic resonance imaging and positron emission computed tomography are presented in this Etiology Examples paper. Furthermore, dietary treatment, pharmacological Pharmacological A. Commonly prescribed medications: treatment (anti-5-hydroxytryptamine3 [anti-5HT3], anti- - Anticholinergics, PPIs D 2, peptide agonists associated with gastric emptying, - Calcium channel blockers antidepressants, and macrolides), gastric electrical stimula- - Cyclosporine tion and surgical approaches are also described. - Exenatide - Pramlintide WHAT IS KNOWN ABOUT GASTROPARESIS? - Lithium - Octreotide B. Controlled substances: The main causes of gastroparesis are of endocrine, neuro- - Narcotics logical and metabolic origin. It usually occurs in diabetic patients, after undergoing surgeries involving vagotomy Mechanical Superior mesenteric artery syndrome Median arcuate ligament syndrome and by unknown causes (idiopathic gastroparesis) (Table Median arcuate ligament syndrome 1). Symptoms are variable and include nausea, vomiting, early satiety, anorexia, weight loss, and epigastric pain (1). Metabolic Neuromyelitis optica with aquaporin-4 Pathophysiological alterations in patients with gastropa- autoantibodies (astrocytic water channels) resis are associated with (Figure 1): Psychiatric Anorexia nervosa 1. Impaired gastric accommodation caused by loss of gas- Bulimia nervosa tric inhibitory peptides or vagus nerve damage. Endocrine Hypothyroidism 2. Depletion of interstitial cells of Cajal in diabetes cases Adrenal insufficiency and post-infection lesions, resulting in arrhythmias Diabetes mellitus (e.g., tachygastria and ectopic pacemakers, associated CNS disorders Multiple sclerosis with nausea and vomiting). Parkinson’s disease 3. Abnormal smooth muscle contractions due to altered function of the neurons of the enteric nervous system. Paraneoplastic ANNA-1, sometimes called anti-Hu 4. Atrophy or fibrosis of the smooth muscle. 5. Altered release of gastrointestinal peptides (motilin, ANNA-1: type 1 anti-neuronal nuclear antibodies; PPI: Proton pump inhibitors. ghrelin, and pancreatic polypeptide, which facilitate gastric motility). 6. Pyloric sphincter dysfunction and the concept of pylo- ric spasm (2). Patients with functional dyspepsia show exaggerated sensitivity to gastric distension, which suggests the contri- Patients with gastroparesis have nonspecific symptoms bution of afferent neuron dysfunction to the pathogenesis that can simulate those of structural disorders such as ulce- of the symptom. Also, in diabetic patients with symptoms ropeptic disease, partial gastric or intestinal obstruction, of dyspepsia, gastric distension causes nausea, meteorism gastric cancer, and pancreatic biliary disorders. Symptoms and marked abdominal discomfort. It is believed that these of gastroparesis and functional dyspepsia also overlap; the symptoms may be caused by sensory nerve dysfunction in latter is characterized by experiencing chronic or recurrent these patients (7, 8). discomfort in the upper abdomen, although many people In up to half of patients undergoing routine examinations report dysmotility together with nausea, vomiting, and such as upper gastrointestinal (GI) endoscopy or gastroin- early satiety, and some subgroups of patients experience testinal endoscopy (GE) and laboratory tests, the identifi- delayed gastric emptying (3, 4). cation of organic or biochemical abnormalities that easily The correlation of symptoms with delayed gastric emp- explain gastroparesis symptoms is not possible. In most tying is variable in diabetic gastropathy, idiopathic gas- adults, gastroparesis is idiopathic. Complications asso- troparesis, and functional dyspepsia cases. Recent studies ciated with this disease may include Mallory-Weiss tears, have reported that early satiety, postprandial fullness, and bezoar formation, malnutrition, aspiration pneumonia, vomiting predicted delayed gastric emptying in patients and electrolyte disorders (3, 4). with functional dyspepsia (3, 4). In addition, a feeling of These so-called functional gastrointestinal disorders are fullness and meteorism have been found to predict delayed highly prevalent, misunderstood, and have a great health gastric emptying in patients with diabetes (5, 6). care and socioeconomic impact. Therefore, it is important 472 Rev Colomb Gastroenterol. 2020;35(4):471-484. https://doi.org/10.22516/25007440.561 Review article Normal gastric Gastric motility controlled by gastric Vagal neuropathy: slow waves originating from ICC Gastroparesis - Decreased antral function and sweep along gastric smooth contraction muscle cells - Decreased gastric tone - Deterioration of antroduodenal Direct toxic incoordination chronic effects of - Antral hypomotility Electrical activity the presence of - Pylorospasm leading to origins in the fundus glucose in metabolic delayed emptying of solids and the body of the pathways stomach (3 cycles/min) Retained food (bezoar) Small intestine motility Depletion and disruption of the role in the grinding of ICC network the stomach contents Waves are conducted circumferentially and distally to the pylorus with action potentials Gastric electrical dysrhythmias Ghrelin Cholecystokinin Motilin * electromechanical coupling signaling (tachygastria and altered conductivity) (muscle contraction). Impaired GI peptids modulate post-prandial intestitanl motility Motilin Ghrelin gastric nutrient emptying and bacterial The enteric nervous system integrates overgrowth neurohormonal control and coordination Imbalance of postprandial Loss of electromechanical coupling and of muscle contractility, sphincter hormone release worsening of gastric contractions relaxation and function Figure 1. Gastroparesis pathophysiology. ICC: Interstitial cells of Cajal. Adapted from: Reddymasu SC, Sarosiek I, McCallum RW. Severe gastroparesis: medical therapy or gastric electrical stimulation. Clin Gastroenterol Hepatol. 2010;8(2):117-24. to understand their possible diagnostic and therapeutic plastic complications most commonly observed in small options (9). cell lung
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