Treatment for Gastroparesis

Gastroparesis is a common complication of both type 1 and type 2 diabetes.  It is a condition in which the muscles of the stomach become weak so that the food isn’t ground up well in the digestive process and there is a decrease in the emptying rate of food from the stomach to the duodenum, which is the first part of the small intestines.

Under normal conditions, the stomach is a strong muscle that digests food through the use of enzymes and stomach acid before sending it down to the duodenum for absorption of the broken down food items.  The food is also broken down by being churned up by the contractions of the muscles of the stomach. This churning breaks the food into small particles so that they are easily digested by the stomach.

The solid and liquid components of food are then emptied from the stomach into the duodenum in a controlled fashion that allows for the gradual absorption of food.  The food is passed through the pylorus of the stomach, where it is further broken down by the digestive enzymes made by the pancreas, liver, and small intestines.  The food is initially stored by the stomach while contractions of the stomach gradually allow for its passage into the other parts of the gastrointestinal tract.

In gastroparesis, the contractions of the stomach muscles become weak so that food is not properly ground up inside the stomach and does not empty well into the duodenum.  Since the contractions of the stomach muscle are weak, the food remains in large particles that are poorly digested and the emptying of food is delayed. Sometimes just the solid food is delayed in stomach emptying but, in less common situations, both solid and liquid food are delayed by weakened stomach muscles.

The Treatment of Gastroparesis

The main goals of the treatment of gastroparesis include the following:

• To allow for maximal nutrition.
• To enhance muscle activity inside the stomach so that the food can be ground properly and then emptied from the stomach into the duodenum.
• To relieve the typical symptoms of gastroparesis, including abdominal pain, nausea, and vomiting.
• To control the underlying medical conditions that make gastroparesis worse.
• To provide the diabetic patient with a diet that includes food that can be more easily digested and emptied through the pylorus into the duodenum.

Dietary Measures

Dietary measures for the management of gastroparesis include allowing the diabetic to eat small, frequent meals that are emptied faster from the stomach when compared to eating larger meals.  Foods that don’t require grinding, such as soft foods, are given as well as mostly liquid foods.

Liquid food seems to be able to be more completely emptied from the stomach when compared to solid food so this is preferred over solid food in the treatment of gastroparesis.  Fat is reduced in this type of diet because it stimulates the release of hormones that ultimately slow gastric emptying.  For this reason, the diet of a diabetic with gastroparesis is usually low in fat.

If the gastroparesis is extremely severe, sometimes only food that is liquid can be given.  Another recommendation for patients with gastroparesis include providing the diabetic patient with a low fiber diet because foods that are high in fiber are poorly digested and bezoars can form in the stomach.  If this should occur, gastric emptying is decreased.

It is recommended that the food eaten by an individual with gastroparesis should be well chewed before swallowing because the normal stomach action of grinding is lessened in this disease.  Food is given with plenty of fluids to make sure that most of the diet is liquids.  Liquids pass through the pylorus faster than solids.

Food should be eaten early in the day as much as possible.  This is especially true of solid foods. The patient should be instructed to remain upright for 4 to 5 hours after eating as gastric emptying is improved by gravity and lying down decreases the emptying of the gastric contents.  In addition, multivitamins are recommended because the diabetic with gastroparesis faces an increased chance that the vitamins in food are passed through the gastrointestinal tract, rather than being absorbed by the small intestines.

Controlling the Underlying Problem

Gastroparesis is also managed by helping the diabetic patient to reduce the blood sugars as much as possible. High blood sugar levels delay gastric emptying.  For this reason, strict control over the blood sugars should be recommended.  If thyroid disease is contributing to the gastroparesis, this is treated by giving the patient thyroid hormones.  If the patient has developed a bezoar (a mass of undigested food in the stomach), the bezoar should be removed to enhance stomach emptying.

Relieving the Symptoms of Gastroparesis

Medications are often used to treat gastroparesis.  Drugs that improve the motility of the stomach include Reglan (metoclopramide) and anti-nausea medications, such as Compazine (prochlorperazine) and Phenergan (promethazine).  Sometimes serotonin blockers like Zofran, the scopolamine patch, and Marinol (medial marijuana) are used to treat gastroparesis.

The abdominal pain of patients with gastroparesis is often treated by providing the patient with nonsteroidal anti-inflammatory medications (NSAIDs), tricyclic antidepressants (amitriptyline), Neurontin (gabapentin), and narcotic medications.  These help treat the pain found in gastroparesis but will not treat the delayed stomach emptying. Narcotics should be used carefully as they tend to cause constipation and actually decrease the rate of stomach emptying.

Treating Gastroparesis by stimulating Muscle Activity

There are drugs that can be giving that increase the motility of the stomach.  These include Propulsid (cisapride), erythromycin, Reglan (metoclopramide), and domperidone. The act to treat gastroparesis by allowing for increased muscle contractions so that stomach emptying can be increased.  Zelnorm (tegaserod) is usually used for the treatment of irritable bowel syndrome but has also been found to improve gastric emptying.

In treating patients with gastroparesis, it should be emphasized that the medications must be given at the proper times in order for them to be effective in treating the condition and they must be able to travel to the small intestines, where they can be absorbed in order to manage gastroparesis.  Most drugs, for example, that are used to stimulate the contractions of the stomach after eating, should be given just before the meal so that the contractions can be stimulated at the right time (after the meal).

Most people with gastroparesis will have a delay in stomach emptying of both solid food and medications given in pill or capsule form.  For this reason, sometimes liquid medications are given to treat gastroparesis rather than taking the medications as pills, which might not reach the intestinal lining and might not be absorbed.

Optimizing Nutrition

Patients with gastroparesis that isn’t too severe can be treated with medications that improve stomach motility and treat the pain associated with the disease; however, people with severe gastroparesis often become dehydrated and malnourished.  These patients need to be hospitalized on a periodic basis in order to correct the malnutrition and dehydration seen in severe disease.

References:

• How is gastroparesis treated? http://www.medicinenet.com/gastroparesis/page4.htm
• What is gastroparesis? http://www.medicinenet.com/gastroparesis/article.htm