Many people with gastroparesis will respond to medical management including some dietary modification. However, medication failures or side effects are common. Many physicians have little knowledge or experience with treating gastroparesis.
Some practical things to consider when treatment does not seem to help include:
- Check the diagnosis
- The cause matters
- Review the diet
- Consider other medications
- Treat the pain
- Manage the psychosocial aspects
- Know when to consider surgery
- Be persistent and be careful
Check the Diagnosis
Nausea is the hallmark symptom of gastroparesis. Other medical problems should be considered when nausea is not a prominent symptom.
Dyspepsia is characterized by pain/burning in the mid-upper abdomen and/or bothersome fullness following a normal sized meal and/or inability to complete a meal (early satiety). People with esophageal diseases such as gastroesophageal reflux disease (GERD) or achalasia can have abnormal gastric emptying studies.
Nausea may be a secondary symptom in people with countless other medical problems. Cyclic vomiting syndrome (CVS) is a disorder where otherwise completely healthy people have stereotypical intermittent episodes of severe nausea, vomiting, and abdominal pain. People with intestinal pseudo obstruction have prominent symptoms of bloating and severe constipation. Rumination syndrome is characterized by constant regurgitation and either vomiting or re-swallowing food or drink soon after eating. Small bowel obstruction should be considered in people who have had previous abdominal surgery.
The Cause of the Gastroparesis Matters
In diabetic gastroparesis it is important to control the blood sugar, as intestinal motility is impaired when the blood sugar is elevated. Intravenous erythromycin should be considered in hospitalized patients with diabetes. Unfortunately, erythromycin seems to be beneficial for only a few days at a time.
Patients with idiopathic post-viral gastroparesis usually improve over the course of time, ranging from several months to one or two years. During that period it is important to consider that any irreversible surgical procedures not be performed in these patients to treat idiopathic post-viral gastroparesis.
Identifying and treating any underlying systemic disorder may rarely help, and is worth the effort.
Review the Diet
Many physicians tend to skip dietary recommendations, although it is the area of most interest to patients. It is important to review the low-fat, low-fiber diet and to discuss nutritional supplements.
Rarely, feeding tubes and total parenteral nutrition are necessary. Enteral feeding tubes should be placed in the jejunum, not the stomach. These should not be considered early in the course of the patient’s illness, as they are not without risk. They must be carefully managed to avoid serious complications like infection.
Consider Other Medications
The utility of the prokinetic agents is often limited by their side effects. There is a good bit of anecdotal evidence that medications like amitriptyline can decrease the sensation of nausea. The typical dose is 25–50 mg at bedtime, which is well below the dose that is required to treat depression. A doctor can check blood levels, and modify the dose accordingly. Side effects, including blurry vision, urinary retention, sleepiness and constipation are uncommon because of the low dose.
Bacterial overgrowth (SIBO) may accompany gastroparesis. The main symptom is bloating. Judicious use of antibiotics and probiotics may be helpful in the management of these symptoms.
It is difficult for patients with nausea and vomiting to tolerate oral medications. Obviously, hospitalized patients should receive intravenous medication. Outpatients may do better with medication that dissolves in the mouth.
Reports from highly specialized (tertiary) medical centers that often see people with severe gastroparesis suggest that bloating is a common symptom. Bloating impairs quality of life. Bloating severity appears related to intensity of other gastroparesis symptoms but is not affected by gastric emptying rates. Antiemetics, probiotics, and antidepressants with significant norepinephrine reuptake inhibitor activity may help.
Treat the Pain
Abdominal pain may be overlooked in gastroparesis. However, controlling abdominal pain can be the key to success in the management of many patients. Pain does not correlate with gastric emptying. Non-steroidal anti-inflammatory drugs (NSAIDs) may help. Low dose tricyclic medications, such as amitriptyline, nortriptyline, and desipramine, have been shown to reduce pain in other functional gastrointestinal (GI) conditions and may reduce pain associated with gastroparesis. Other drugs found useful in treating neuropathic pain may be tried. Opiates, or narcotics, should be avoided.
Manage the Psychosocial Aspects
Not surprisingly, anxiety and depression are very common in people with chronic debilitating illnesses. The physician and staff need to have compassion and patience. If necessary, psychological consultation should be considered. Low dose tricyclic medications do not treat anxiety or depression. Real emotional disorders require real psychological treatment. Appropriate treatment can lead to improvement in the GI symptoms.
Patients with an eating disorder may be given a diagnosis of gastroparesis. However, it is probably more common for patients with gastroparesis to be accused of having an eating disorder, rather than actually having one.
When to Consider Surgery
Patients failing medical therapy should have a thorough evaluation before considering surgical therapy. Surgical procedures all have inherent risks that need to be carefully weighed and understood. Most surgical treatments are irreversible, but work in carefully selected patients, having the correct surgery done, by an experienced and accomplished surgeon.
Be Persistent and Be Careful
Most medications work only less than half of the time. Nonetheless, most people will respond to some therapy. If a medication causes side effects, consider a lower dose. If it doesn’t work, try something else. Combining medications may be helpful. The effectiveness of various agents differs between individuals. Importantly, a medication regimen must be carefully chosen under the direction of the physician. Keep hydrated and as nutritionally fit as possible.
When treatment is failing and there appear to be no other options – whether you are the patient or the physician – get another opinion. Persistence pays off, as most people with gastroparesis ultimately will do well.
Adapted from IFFGD Publication: Gastroparesis (Delayed Gastric Emptying) by J. Patrick Waring, MD, Digestive Healthcare of Georgia, Atlanta, GA; and William F. Norton, Communications Director, International Foundation for Functional Gastrointestinal Disorders, Milwaukee, WI.