1. Diabetic Gastroparesis
Ali Djumhana
Div. Gastroenterology dan Hepatologi
Bagian Ilmu Penyakit Dalam RS Hasan Sadikin – FK Unpad
Bandung

2. Gastroparesis
 Gastroparesis is a form of gastric paralysis ;chronic symptoms may
result from abnormal gastric motility associated with delayed
gastric emptying in the absence of mechanical outlet obstruction.
 The symptoms that suggest gastroparesis are variable include
nausea, vomiting, abdominal bloating, early satiety , and
abdominal pain or discomfort
 The symptoms may mimic structural disorders
(PUD,intestinalobstruction,pancreatobliary disorders) and there
also overlap between symptoms of gastroparesis and FD
 Relationship of symptoms to gastric motor function is poor
Parkman HP ( 2004); Park MI(2006)

3. Etiology of Gastroparesis
28%
8%
29%
14%
10%
4%
4% 3%
Idiopathic
Postviral
Diabetic
Postsurgical
Parkinsons
Pseudoobstruction
Scleroderma
Miscellaneous
Soykan I et al. (1998)

4. Epidemiology
 Female > Male (~ 4:1)
 Delayed gastric emptying were found :
– 20 - 40 % of pts with F D
– 26 - 68% % of pts with Diabetes
 Incidence of delayed gastric emptying:
– 4.5% DM 1
– 1% DM 2
– 0.1% Non DM

5. Physiology of Gastric motility

6. =Parasympatetic ( N Vagus)
=Sympatetic
=Enteric neural system
=Neurotransmitter
(Acetylcholine,dopamin,
serotonin)
=Hormone ( glucose regulating
hormone)
=Food composition
(fat,CHO,solid,fluid)
Regulation of gastric motility

7. Physiology of gastric motility
Motor function of stomach is controlled at three
main levels
 Autonomic nervous system
 Enteric neuronal system
 Interstitial Cell of Cajal
 Smooth muscle cell
Several subsystems are involved:
 afferent receptors
 neurohumoral substances
 circulating hormones
ICCs
ICCs

8. Motility of the gut
excitation
inhibition

9. Physiology of gastric emptying
Gastric emptying results of :
 Tonic contraction of the fundus,
 Phasic contraction of the antrum,
 Inhibitory forces of pyloric and duodenal
contraction

11. Pathophysiology Diabetic gastropsresis
Gut 2010;59:1716-1726

12. Pathophysiology Diabetic gastroparesis

13. Pathophysiology of Gastroparesis
Abnormal gastric motility
 Abnormal gastric accommodation
 Gastric dysrhythmias
 Antral hypomotility

14. Evaluation of patients suspected
gastroparesis
 Gastroparesis is diagnosed by demonstrating
delayed gastric emptying in a symptomatic
individual after exclusion of other etiologies of
symptoms
 Gastroparesis is often suspected in patient
subgroup with specific profile
 DM
 After vagotomy
 FD
 GERD
Parkman HP ( 2004); Rayner CK (2005)
Park MI(2006)

15. Evaluation of patients suspected
gastroparesis
 HT and PE
 Laboratory testing
 Evaluation for organic disorders
 Evaluation for delayed gastric emptying
 Evaluation of response to treatment trial
 Further evaluation

16. History taking and Physical Examination
 HT
 Differentiated of vomiting from regurgitation and ruminating
 Risk factors
 Poor glycaemic controlled
 Female
 History of medication (GLP-1 agonist/receptor analogue,etc)
 PE
 Hydration status
 Nutrition status
 Succussion splash

17. Diagnosis
Gut 2010;59:1716-1726

18. Evaluation of patients
Suspected Gastroparesis

19. Test to assess gastric motor and myoelectrical function
 Assessing gastric emptying
 Upper Ba radiography study
 Scintigraphy
 USG
 MRI
 Breath test
 Assessing gastric contractility
 Antroduodenal manometri
 Gastric barostat
 Satiety test
 Assessing electrical activity
 EGG

20. Treatment of symptomatic
gastroparesis
 Nutrition teraphy
– Hydration and corection of electrolite imbalance
– Liquid or parenteral nutrition
– Micronutrient
– Vitamins ( Cobalamin,vitamin C, etc)
 To tighten glicaemic control
 Prokinetic agents
 Anti emetic agents
 Others modality
– Botulinum injection
– Gastric electrical stimulation
– Gastrostomy and jejunostomy placement
– Surgical treatment

21. Treatment of symptomatic
gastroparesis
 Dietary modification
– Liquid diet is recommended to patient with
gastroparesis who have delayed solid emptying
– Frequent (4 – 5 x daily) and small size diet
– Minimized fat and fiber intake
– Avoid alcohol and carbonated beverages
 To tighten glicaemic control.

22. Treatment of symptomatic gastroparesis
Medical treatment
 Prokinetic agent
– Dopaminergic agent
 Dopaminergic antagonist
– Metoclopramide
– Domperidone
– Mosapride
– Serotonergic agent
 5HT4 agonist
– Pucalopride
– Cisapride
– Tegaserod
 5HT3 antagonist
– Ondansetron,granisetron
– Motilin agonist
 Eritromycin
 Antiemetic agent
– Phenotiazine
 Psychotropic
– Benzodiazepin
– Antidepresant

23.  New and other agents
 Motilides
– Mitemcinal
– ABT 229
 CCK antagonist
– Loxiglumide
 NO donors
– Sidenafil ?
 Ghrelin
 5 HT1 agonist
– Sumatriptan
– Buspiron
Treatment of symptomatic
gastroparesis

24. Commonly used prokinetic drugs
Rayner CK and Horowitz M (2005) New management approaches for gastroparesis
Nat Clin Pract Gastroenterol Hepatol 2: 454–462 doi:10.1038/ncpgasthep0283

25. Treatment of symptomatic gastroparesis
Others therapeutic modalities
 Endoscopic treatment
– Botulinum toxin injection
 Gastric electric stimulation
 Gastrostomy and jejunostomy placement
 Ginger, Acupuncture
 Surgical treatment

26. Improvement
Presumptive diagnosis of gastroparesis
Assessment of patients to rule out mechanical obstruction or another diseases
Nutrition;glycaemic control
Empiric trial of prokinetic for 4-8 wks
History of symptoms gastroparesis
No improvement
Treatment continue
And Pulse Tx
Perform UG-Endos/ Ba meal
Negative finding Structural lesion
Appropriate Tx
High dose
medical Tx
Test Gastric emptying
Improvement No Improvement
Abnormal Normal
High dose prokinetic
Or other modalities
Re-evaluate the D/
Improvement

27. Conclusion (1)
 Gastroparesis is a syndrome characterized
by delayed gastric emptying in the
absence of mechanical obstruction
 Diabetic gastroparesis is the main cause of
gastroparesis
 Scintigraphy is a gold-standard for
diagnosis

28. Conclusion (2)
 Patients with presumptive diagnosis
gastroparesis should be cared for empirical /
trial treatment.
 The treatment include ;Nutrition teraphy
(Macro and micro nutrient,vitamins
etc), metabolic control and prokinetic agent
 Novel treatment including new
prokinetics, botulinum toxin injection,gastric
electrical stimulation have been tested in
patients with gastroparesis