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Delayed gastric emptying, gastroparesis, is one of the sequelae of diabetes mellitus. Symptoms may include postprandial nausea, epigastric pain, bloating, vomiting, early satiety and unpredictable blood sugar fluctuations. Nowadays diagnosis is made by the measurement of gastric emptying with a radionuclide test meal. Using this technique some 50% of diabetic patients show signs of disordered gastric emptying. Relief is best delivered by agents promoting gastric emptying. In phase II single-dose studies metoclopramide, domperidone, cisapride, erythromycin and renzapride were all able to enhance gastric evacuation of solid and liquid meals in patients with diabetic gastroparesis. A few short term studies support the efficacy of domperidone and renzapride, but long term trials are lacking. Erythromycin, mimicking the potent gastrokinetic effect of motilin, may hold considerable promise for the future. Experience with erythromycin in diabetic gastroparesis is nonetheless very limited. To some extent the therapeutic effectiveness of metoclopramide and cisapride has been established in placebo-controlled trials. In trials with a placebo-controlled crossover design, however, only metoclopramide showed a sustained positive effect. Metoclopramide, which combines gastrokinetic and antiemetic properties seems, so far, the best therapeutic option in diabetic gastroparesis. Cisapride may be considered as a good alternative in cases where limited efficacy or side effects preclude the use of metoclopramide.
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PMID:Diabetic gastroparesis. A critical reappraisal of new treatment strategies. 128 Oct 70

In a recent editorial, Kapur described perioperative nausea and vomiting as "the big 'little problem' following ambulatory surgery."257 Although the actual morbidity associated with nausea is relatively low in health outpatients, it should not be considered an unavoidable part of the perioperative experience. The availability of an emesis basin for every patient in the postanesthesia recovery unit is a reflection of the limited success with the available therapeutic techniques.257 There had been little change in the incidence of postoperative emesis since the introduction of halothane into clinical practice in 1956. However, newer anesthetic drugs (e.g. propofol) appear to have contributed to a recent decline in the incidence of emesis. Factors associated with an increased risk of postoperative emesis include age, gender (menses), obesity, previous history of motion sickness or postoperative vomiting, anxiety, gastroparesis, and type and duration of the surgical procedure (e.g., laparoscopy, strabismus, middle ear procedures). Anesthesiologists have little, if any, control over these surgical factors. However, they do have control over many other factors that influence postoperative emesis (e.g., preanesthetic medication, anesthetic drugs and techniques, and postoperative pain management). Although routine antiemetic prophylaxis is clearly unjustified, patients at high risk for postoperative emesis should receive special considerations with respect to the prophylactic use of antiemetic drugs. Minimally effective doses of antiemetic drugs can be administered to reduce the incidence of sedation and other deleterious side effects. Potent nonopioid analgesics (e.g., ketorolac) can be used to control pain while avoiding some of the opioid-related side effects. Gentle handling in the immediate postoperative period is also essential. If emesis does occur, aggressive intravenous hydration and pain management are important components of the therapeutic regimen, along with antiemetic drugs. If one antiemetic does not appear to be effective, another drug with a different site of action should be considered. With the availability of new antiserotonin drugs, the incidence of recurrent (intractable) emesis could be further decreased. Research into the mechanisms of this common postoperative complication may help in improving the management of emetic sequelae in the future. As suggested in a recent editorial, improvement in antiemetic therapy could have a major impact for surgical patients, particularly after ambulatory surgery. Patients as well as those involved in their postoperative care look forward to a time when the routine offering of an emesis basin after surgery becomes a historical practice.
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PMID:Postoperative nausea and vomiting. Its etiology, treatment, and prevention. 843 45

Dyspepsia can be defined as the presence of upper abdominal pain or discomfort; other symptoms referable to the proximal gastrointestinal tract, such as nausea, early satiety, and bloating, may also be present. Symptoms may or may not be meal related. To be termed chronic, dyspepsia should have been present for three months or longer. Over half the patients who present with chronic dyspepsia have no evidence of peptic ulceration, other focal lesions, or systemic disease and are diagnosed as having non-ulcer (or functional) dyspepsia. Non-ulcer dyspepsia is a heterogeneous syndrome. It has been proposed that this entity can be subdivided into a number of symptomatic clusters or groupings that suggest possible underlying pathogenetic mechanisms. These groupings include ulcer-like dyspepsia (typical symptoms of peptic ulcer are present), dysmotility (stasis)-like dyspepsia (symptoms include nausea, early satiety, bloating, and belching that suggest gastric stasis or small intestinal dysmotility), and reflux-like dyspepsia (heartburn or acid regurgitation accompanies upper abdominal pain or discomfort). The aetiology of non-ulcer dyspepsia is not established, although it is likely a multifactorial disorder. Motility abnormalities may be important in a subset of dyspepsia patients but probably do not explain the symptoms in the majority. Epidemiological studies have not convincingly demonstrated an association between Helicobacter pylori and non-ulcer dyspepsia. Other potential aetiological mechanisms, such as increased gastric acid secretion, psychological factors, life-event stress, and dietary factors, have not been established as causes of non-ulcer dyspepsia. Management of non-ulcer dyspepsia is difficult because its pathogenesis is poorly understood and is confounded because of a high placebo response rate. Until more data are available, it seems reasonable that treatment regimens target the clinical groupings described above. Antacids are no more effective than placebo in non-ulcer dyspepsia, although a subgroup of non-ulcer dyspepsia patients with reflux-like or ulcer-like symptoms may respond to H2-receptor antagonists. However, there is no significant benefit of these agents over placebo in many cases. Bismuth has been shown to be superior to placebo in patients with H. pylori in a number of studies, but these trials had several shortcomings and others have reported conflicting findings. Sucralfate was demonstrated in one study to be superior to placebo, but this finding was not confirmed by another group of investigators. Prokinetic drugs appear to be efficacious, and may be most useful in patients with dysmotility-like and reflux-like dyspepsia.
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PMID:Non-ulcer dyspepsia: myths and realities. 188 33

We recently have shown that 50% of patients with preoperative gastric outlet obstruction go on to develop chronic nonmechanical gastric stasis after surgery and require further operations in attempts to relieve their symptoms. In the present study we report our experience with completion gastrectomy (CG), offered to a subgroup of this population who failed to respond to both available and experimental medical therapy with prokinetic agents. Manometric studies of the small bowel were performed on three of these patients using a semiconductor solid recording probe to assess the motility of efferent jejunal limbs. There were seven females and one male (N = 8) with a mean age of 45 years. All had persistent symptoms of abdominal pain, bloating, nausea, vomiting, early satiety, decreased appetite, and weight loss dating back to the time of surgery. Gastric stasis was documented by delayed gastric emptying of a radionuclide solid meal (chicken liver labeled with technetium-99m sulfur colloid) with a mean retention of 86 +/- 6.2% (less than 60% being normal) in the setting of an upper endoscopy showing stomal patency. The mean duration of symptoms was 31.6 +/- 15.7 months (range 6-60) since the last surgery. The number of previous gastric operations was a mean of 2.3 per patient. Five of eight patients had undergone a Roux-en-Y procedure as the last operation while the other three had a Billroth II. Surgery consisted of a 90% or complete resection of the remaining stomach and a jejunal-esophageal anastomosis. In some cases the Roux-en-Y limb was lengthened to greater than 45 cm if needed.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Completion gastrectomy for refractory gastroparesis following surgery for peptic ulcer disease. Long-term follow-up with subjective and objective parameters. 193 93

We investigated the safety and efficacy of short-term s.c. administration of metoclopramide in the treatment of symptomatic gastric stasis. Ten patients with gastroparesis, documented by abnormal solid phase radionuclide gastric emptying study, were treated with 10 mg (2 ml) of s.c. metoclopramide every 6 hr for 3 days. Patients gave themselves the injections as outpatients. Questionnaires were then completed concerning symptom relief, local side effects and adverse reactions. A repeat gastric emptying study was obtained immediately after the last dose of metoclopramide. Serum metoclopramide concentrations were obtained at trough, 1, 2, 3, 4 and 5 hr postadministration and serum prolactin levels at trough, 1 and 3 hr. Pharmacokinetic analysis showed mean peak metoclopramide concentration at 30 min of 99.7 +/- 47.1 ng/ml with measured levels of 93.9 +/- 106.83 ng/ml at 60 min and return to trough values by 4 hr; trough prolactins remained elevated above normal values. Gastric stasis improved from a base-line retention of 78.7% of radioisotope at 2 hr to 72.5% after 3 days of therapy (P = .65). Eight patients reported significant improvement in symptomology and two patients reported lessening of symptoms such as nausea, vomiting, bloating, abdominal pain, heartburn and vomiting. The side effects were minimal and did not interfere with completion of the protocol. We demonstrated that s.c. administration of metoclopramide was well accepted by patients and resulted in subjective and objective improvement of gastric stasis. In addition, serum metoclopramide concentrations were comparable with other parenteral routes of administration. Furthermore, serum prolactin levels may provide both a bioassay of efficacy and a marker for monitoring compliance.
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PMID:Subcutaneous metoclopramide in the treatment of symptomatic gastroparesis: clinical efficacy and pharmacokinetics. 207 91

Thirty-seven consecutive patients referred to a regional gastroenterology outpatient clinic with complaints of persistent nausea had a double isotopic scintigraphic evaluation of solid and liquid gastric emptying. Gastric emptying of both forms followed an exponential model. Marked day to day variation of gastric emptying was noted with a coefficient of variation of approximately 0.20 for both phases. Only 9 of 37 patients had delayed gastric emptying rate of the solid component (greater than 180 min) and no correlation between gastric stasis syndrome and nausea was established. Among these patients the median time for the stomach to empty 50% of the solid component was 261 min and 50% of the liquid component was 66 min. Treatment of these 9 patients shown to have gastric stasis syndrome and further 3 patients with diabetic gastroparesis with ondansetron, a highly selective antagonist of 5-hydroxytryptamine-3-receptors, resulted in a gastric emptying rate which was not statistically faster than after placebo (p = 0.11).
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PMID:Gastric emptying and subjective symptoms of nausea: lack of effects of a 5-hydroxytryptamine-3 antagonist ondansetron on gastric emptying in patients with gastric stasis syndrome. 214 64

The pathophysiology, diagnosis, and treatment of diabetic gastroparesis are reviewed, and the mechanisms of action, pharmacokinetics, clinical efficacy, adverse effects, and dosage of metoclopramide, domperidone, and cisapride are described. Diabetic gastroparesis is a state of delayed gastric emptying that reportedly affects 20-30% of diabetic patients. Symptoms include nausea, early satiety, postprandial bloating and fullness, and vomiting. Diabetic gastroparesis has been managed most successfully with drugs that stimulate gastric emptying. Of the three agents studied--metoclopramide, domperidone, and cisapride--only metoclopramide is commercially available in the United States. The clinical efficacy of metoclopramide, domperidone, and cisapride has been well documented in several placebo-controlled trials. Metoclopramide effectively decreases mean gastric emptying time, although tolerance to this stimulation of gastric emptying may develop with long-term therapy. However, symptomatic relief persists with long-term therapy because of metoclopramide's antiemetic properties. Domperidone, which has also been shown to stimulate gastric motility and to possess antiemetic properties, improves symptoms in patients suffering from diabetic gastroparesis. Cisapride appears to have continued beneficial effects on gastric motility with long-term therapy. All three agents have favorable adverse-effect profiles. Although metoclopramide is currently the first-line agent for the management of gastroparesis, domperidone and cisapride both possess properties that may make them useful alternatives in patients who are unresponsive to or cannot tolerate metoclopramide therapy.
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PMID:Use of metoclopramide, domperidone, and cisapride in the management of diabetic gastroparesis. 219 Jul 45

Patients with chronic nausea and vomiting frequently present challenging diagnostic and therapeutic problems. In such patients, gastroparesis of unknown cause, or "idiopathic" gastroparesis, may be the only objective finding. Two middle-aged women with nausea, vomiting, and weight loss of 10 and 26 kg over 6 and 18 months, respectively, were evaluated. Routine laboratory and barium study results were normal. Solid-phase gastric emptying studies showed severe gastroparesis in both patients. Upper endoscopies excluded gastric outlet obstruction. Gastric dysrhythmias (4-cpm and 1-cpm patterns) were recorded using cutaneous electrodes. An abdominal bruit was ascultated in one patient. Abdominal arteriograms in both patients showed total occlusion of all three major mesenteric vessels with collaterals supplied via hemorrhoidal arteries. Bypass grafting procedures of the celiac and superior mesenteric arteries in one patient and of the celiac artery in the other patient were performed. Six months after mesenteric artery revascularization, upper gastrointestinal symptoms had resolved and original weights were regained. Furthermore, normal 3-cpm gastric myoelectrical activity and normal gastric emptying of solids were restored in both patients. In these patients, chronic mesenteric ischemia resulted in a novel and reversible cause of gastroparesis, gastric dysrhythmias, and accompanying symptoms.
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PMID:Ischemic gastroparesis: resolution after revascularization. 234 30

Gastroparesis after a viral infection has rarely been reported. In this article, we describe the clinical features and long-term outcome of 7 patients who had gastroparesis after a presumed viral illness and who were identified in a retrospective review of 103 consecutive cases of gastroparesis seen at our institution from 1977 through 1988. The three male and four female patients with gastroparesis after a suspected viral illness were young (mean age, 26.9 years) and healthy before the onset of the illness, which manifested as low-grade fever, fatigue, and myalgia with or without diarrhea. A mean of 4.5 days after spontaneous resolution of the viral illness, persistent nausea, vomiting, and epigastric pain developed in these patients. In all seven patients, delayed emptying of the gastric contents was substantiated. Autonomic neuropathy was found in all three patients who underwent autonomic function tests. During a mean follow-up of 32.3 months, five of the seven patients had complete resolution of gastroparetic symptoms, and the other two had considerable improvement of their condition. We conclude that postviral gastroparesis is uncommon, is frequently associated with autonomic dysfunction, and is associated with an apparently excellent prognosis.
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PMID:Gastroparesis after a presumed viral illness: clinical and laboratory features and natural history. 234 27

Gastric motor dysfunction and concomitant gastric stasis have been implicated in the pathogenesis of nonulcer dyspepsia, but a cause-and-effect relationship is not established. Essential dyspepsia refers to a subgroup of nonulcer dyspepsia patients who have no evidence of irritable bowel syndrome, gastroesophageal reflux, or pancreaticobiliary disease. In 32 patients with essential dyspepsia, and 32 randomly selected dyspepsia-free community controls of similar age and sex, we measured gastric emptying of solids using Tc99m-Sulphur Colloid in a fried egg sandwich. Subjects with neuromuscular or other diseases that may alter gastric emptying were excluded. Symptoms were assessed by a standard questionnaire. Data processing was carried out "blinded" to the subjects' clinical status. Female patients took significantly longer to empty half the initial stomach activity (mean 90 min) than female controls (mean, 73 min; p = 0.02). The rate of emptying at 25 min was also significantly less in female patients than in controls. Female and male controls, and male patients, had similar emptying times. Delayed emptying was not associated with the occurrence of postprandial pain, belching, or nausea; there was a trend for the half-time rate of emptying to be greater in patients with abdominal distention. While gastric emptying of solids is slightly delayed in females with essential dyspepsia as a group, this may not explain their symptoms.
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PMID:Lack of association between gastric emptying of solids and symptoms in nonulcer dyspepsia. 258 62


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