Printed in the Netherlands. Revicki1, Anne M. Objective: This paper summarizes the develop- ment and psychometric evaluation of a new instrument, the Gastroparesis Cardinal Symptom Index GCSI , for assessing severity of symptoms associated with gastroparesis. Methods: The GCSI was based on reviews of the medical literature, patient focus groups, and interviews with clinicians.
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Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed This article has been cited by other articles in PMC.
Abstract Gastroparesis is a motility disorder of the stomach causing delay in food emptying from the stomach without any evidence of mechanical obstruction. The majority of cases are idiopathic.
Patients need to be diagnosed properly by formal testing, and the evaluation of the severity of the gastroparesis may assist in guiding therapy. Initially, dietary modifications are encouraged, which include frequent and small semisolid-based meals. Promotility medications, like erythromycin, and antiemetics, like prochlorperazine, are offered for symptom relief.
In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, can be considered. Hemin therapy and gastric electric stimulation are emerging treatment options that are still at different stages of research. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future. Keywords: Gastroparesis, gastric emptying, gastric electrical stimulation, hemin Introduction Gastroparesis is a motility disorder of the stomach characterized by slowed emptying of food into the small bowel in the absence of mechanical obstruction.
Grade 2 patients have moderately severe symptoms but no weight loss and require prokinetic drugs plus antiemetic agents for control. Grade 3 patients are refractory to medication, unable to maintain oral nutrition, and require frequent emergency room visits.
These patients require intravenous fluids, medications, enteral or parenteral nutrition, and endoscopic or surgical therapy. Treatment General measures Most patients with gastroparesis have dehydration and electrolyte disturbances on presentation.
The objectives of treatment at this point include adequate hydration and correction of electrolyte imbalances, management of an underlying disorder ie, diabetes mellitus , and alleviation of the presenting symptoms, such as nausea and vomiting, with medications. Hyperglycemia has been shown to exacerbate the symptoms of gastroparesis, so blood glucose should be optimized appropriately.
Patients presenting with severe symptoms, such as pronounced dehydration or intractable vomiting, may need hospitalization, medications, or even more invasive interventions. However, it must be mentioned that at this time, intrapyloric Botox injections and implantation of a gastric electrical stimulator remain controversial treatment options and offer varying results.
Dietary modifications Dietary recommendations mainly involve adjustments to meal content and frequency. More liquid-based meals are recommended, as these patients usually have preserved gastric emptying with liquids. However, the intake of fats and nondigestible fibers should be discouraged as it is thought to worsen gastric emptying. Parenteral nutrition is usually reserved for patients who fail enteral feeding. But no single agent has been proven to be effective in the management of gastroparesis, thereby making treatment of gastroparesis a challenging task for the health care provider.
Prokinetic medications Prokinetic agents increase antral contractility, correct gastric dysrhythmias, and improve coordination between the antrum and duodenum, thereby promoting the movement of contents from the stomach.
However, the doses required for its gastric emptying effect are much lower than the doses associated with its antibiotic properties. The development of tolerance to the medication is a major problem. Mitemcinal is a macrolide-derived motilin receptor agonist with prokinetic properties. Research has shown that a dose of 10 mg twice daily of mitemcinal had significant effects on upper gastrointestinal symptoms in patients with types 1 and 2 diabetes.
Ghrelin is derived from the gastric mucosa and is similar in structure to motilin. It seems to play an important role in the regulation of appetite and body weight. Ghrelin has been shown to have prokinetic motility-stimulating properties in animals. It was also shown to accelerate gastric emptying after a test meal, in diabetic patients with slow gastric emptying, 21 while another study showed that the administration of ghrelin in patients with idiopathic gastroparesis improved gastric emptying.
It is a benzamide derivative that is structurally similar to procainamide. It primarily acts as a dopamine D2 receptor antagonist but stimulates 5-hydroxytryptamine 4 5-HT4 receptors.
These effects result in the release of acetylcholine within the gut wall, leading in turn to increased lower esophageal sphincter tone, antral contractility, fundic tone, and antroduodenal tone. Discontinuation of the drug should be strongly considered once a suspicion of this side effect arises. Metoclopramide has also been shown to cause or precipitate extrapyramidal movement disorders, such as Parkinsonism, tardive dyskinesia, and akathisia.
Somnolence, anxiety, depression, and reduced mental acuity have also been reported. It chiefly acts as a peripheral dopamine D2 receptor antagonist, with a mechanism of action similar to that of metoclopramide. It accelerates gastric emptying by inhibiting fundic relaxation while promoting antroduodenal coordination and is presently widely used in many countries outside the United States. Sulpiride is another dopamine antagonist that is currently used for some psychotic disorders.
Itopride is a new D2 antagonist with antiacetylcholinesterase effects. Many studies have shown the prokinetic properties of itopride in animals but so far, similar results are lacking in human subjects.
However, it has now been withdrawn from the market due to significant cardiac side effects. Presently, it is only available under compassionate care programs. No other 5-HT4 agonists have been approved for the treatment of gastroparesis.
The 5-HT4-agonist tegaserod has showed conflicting results in studies of gastric emptying in healthy subjects. Recently, BTX has been injected intrapylorically for the treatment of gastroparesis. The BTX injections improve gastric emptying by decreasing the release of excitatory transmitter substances to the pyloric muscles. However, a crossover, randomized study from Belgium of 23 patients with predominantly idiopathic gastroparesis found that BTX was not superior to a placebo injection with respect to effects on symptoms and on gastric emptying.
Gastric electrical stimulation The frequency and direction of gastric peristalsis are determined by the gastric electrical slow wave rhythm. Many experiments in animals have shown that by increasing the electrical stimulation, the peristaltic pressure waves can be increased, resulting in improvement in nausea and vomiting. Surgical interventions Refractory gastroparesis, defined as the failure of symptoms to respond to medical therapy, coupled with the inability to meet nutritional requirements can be encountered in some patients.
In these patients with severe gastroparesis, endoscopic and surgical options should be considered. Surgical placement of a jejunostomy tube should be considered in patients requiring frequent hospitalizations for hydration, nutrition, and medications.
Laparoscopic jejunostomy can be performed safely. Some major complications, such as displacement, obstruction, and aspiration pneumonia, may result after the procedure. If laparoscopy is difficult or impossible to perform because of altered intra-abdominal anatomy, the implantation can be performed by laparotomy. The latter technique prolongs postoperative hospital stay for most patients.
It is believed that high levels of heme oxygenase-1 exert a protective effect on the interstitial cells of Cajal by decreasing oxidative stress. Gastric electrical stimulation has shown promising results in improving gastrointestinal symptoms.
Regarding the goal of achieving sustainable stimulation, alternative options include long-pulse high-energy, single-channel, and multichannel with long pulse gastric electrical stimulation. Stem cells are uncommitted cells characterized by their ability to undergo mitotic division and to cultivate into a variety of differentiated, specialized cells.
Footnotes The authors report no conflicts of interest in this work. References 1. Hasler WL. Gastroparesis: symptoms, evaluation, and treatment. Gastroenterol Clin North Am. Natural history of diabetic gastroparesis. Diabetes Care. Highly variable gastric emptying in patients with insulin dependent diabetes mellitus.
Gastroparesis in diabetes mellitus: an ultrasonographic study. Rom J Gastroenterol. Gastroparesis: prevalence, clinical significance and treatment. Can J Gastroenterol. Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis.
Dig Dis Sci. Esophagitis and gastroduodenal disorders associated with diabetic gastroparesis. Arch Intern Med. Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index.
Aliment Pharmacol Ther. Treatment of gastroparesis: a multidisciplinary clinical review. Neurogastroenterol Motil.
Hyperglycaemia slows gastric emptying in type 1 insulin-dependent diabetes mellitus. Physiological hyperglycemia slows gastric emptying in normal subjects and patients with insulin-dependent diabetes mellitus. Effects of fat on gastric emptying of and the glycemic, insulin, and incretin responses to a carbohydrate meal in type 2 diabetes. J Clin Endocrinol Metab. Emerson AP. Foods high in fiber and phytobezoar formation. J Am Diet Assoc. Influence of meal weight and caloric content on gastric emptying of meals in man.
Gastric emptying of varying meal weight and composition in man. Evaluation by dual liquid- and solid-phase isotopic method. Talley NJ. Diabetic gastropathy and prokinetics. Am J Gastroenterol. Diabetic gastroparesis: effect of metemcinal by subgroup analysis in a week, randomized, multi-center, double blind, placebo-controlled phase 2b study. Effect of atilmotin on gastrointestinal transit in healthy subjects: a randomized, placebo-controlled study. Ghrelin enhances gastric emptying in diabetic gastroparesis: a double blind, placebo controlled, crossover study.
Gastroparesis Cardinal Symptom Index
Eine Gastroparese ist auch bei Herpes-zoster-Infektionen beschrieben Transit-Anomalien auf eine spezifische GI-Region zu lokalisieren ist wichtig bei der diagnostischen Auswertung. Therapie Magensonde, Metoclopramid i. Der Goldstandard zur Evaluierung der Magenentleerungszeit ist die Szintigraphie . Um vergleichbare Resultate zu erhalten, wird empfohlen, eine Standardmahlzeit aus Toast, Marmelade und Ei anzubieten . Eine VME kann dann diagnostiziert werden, wenn nach zwei bzw. Bereits wurde sie von Thomas Willis beschrieben.
Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed This article has been cited by other articles in PMC. Abstract Gastroparesis is a motility disorder of the stomach causing delay in food emptying from the stomach without any evidence of mechanical obstruction. The majority of cases are idiopathic. Patients need to be diagnosed properly by formal testing, and the evaluation of the severity of the gastroparesis may assist in guiding therapy. Initially, dietary modifications are encouraged, which include frequent and small semisolid-based meals. Promotility medications, like erythromycin, and antiemetics, like prochlorperazine, are offered for symptom relief. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, can be considered.
Gastroparesis: a review of current and emerging treatment options
Objective: This paper summarizes the development and psychometric evaluation of a new instrument, the Gastroparesis Cardinal Symptom Index GCSI , for assessing severity of symptoms associated with gastroparesis. Methods: The GCSI was based on reviews of the medical literature, patient focus groups, and interviews with clinicians. A sample of patients with a documented diagnosis of gastroparesis participated in the psychometric evaluation study. A randomly selected sub-sample of 30 subjects returned at 2 weeks to assess test-retest reliability. Clinicians rated severity of symptoms, and both clinicians and patients rated change in gastroparesis-related symptoms over the 8 week study. Internal consistency reliability was 0. Two week test-retest reliability was 0.
Google Scholar 3. Upper gastrointestinal symptoms in North America. Prevalence and relationship to healthcare utilization and quality of life. Dig Dis Sci ;