Hair Loss in Patients with Gastroparesis: A Sign of Nutritional Deficiency in Gastroparesis?

INTRODUCTION: Some patients with gastroparesis (Gp) report hair loss. The aim of this study was to investigate the prevalence of patient-reported hair loss in Gp patients, analyze hair loss association to severity of Gp and nutritional deficiencies, and study effects of multivitamin treatment on hair loss. METHODS: Patients with Gp were questioned about hair characteristics, Gp symptoms, and diet. Patients with hair loss had blood drawn for vitamin levels. Patients with hair loss were treated with daily multivitamin and assessed 8 weeks later. RESULTS: Hair loss was reported in 65 of 143 patients with Gp (45.5%), occurring similarly in idiopathic and diabetic Gp. Hair loss was most commonly noticed while washing and/or combing hair. Patients with hair loss had more severe nausea, abdominal pain, stomach fullness, loss of appetite, abdominal discomfort, bloating, retching, stomach distension, vomiting, early satiety, postprandial fullness, and constipation. Hair loss patients lost more weight over prior 6 months. Patients with hair loss had similar gastric retention on gastric emptying scintigraphy. Overall, 29 of 61 (47.5%) patients with hair loss had at least one abnormal bloodwork result. After 8 weeks of treatment with a daily multivitamin, 17 of 41 (41%) patients had improvement in hair loss. CONCLUSION: Hair loss occurred in 46% of patients with Gp, being associated with more severe symptoms, loss of weight, and several vitamin deficiencies, although not a specific one. Treatment with multivitamins improved hair loss in 40% of patients. Presence of hair loss in patients with Gp should prompt nutritional evaluation and supplementation.

Haloperidol Use in the Emergency Department for Gastrointestinal Symptoms: Nausea, Vomiting, and Abdominal Pain.

INTRODUCTION: Haloperidol (HL) has successfully been used for nausea and abdominal pain in emergency departments (EDs). This study examines outcomes and predictive factors for clinical improvement of patients presenting to an ED with gastrointestinal (GI) symptoms (nausea, vomiting, and abdominal pain) who received HL. METHODS: Review of patients' records who presented to our ED between August 2016 and March 2019 with GI symptoms and received HL. International Classification of Diseases, Tenth Revision codes were used to identify patients. RESULTS: In all, 281 patients (410 encounters) presented to the ED with GI symptoms and received HL for their symptoms: 66% were women, 32% had diabetes, 68% used marijuana, and 27% used chronic opioids. Patients received HL 1.1 ± 0.3 times with dose 2.5 ± 3.0 mg, mostly intravenously (84.6%). Total ED length of stay was 7.5 ± 3.9 hours (3.2 ± 2.1 hours before HL and 4.4 ± 3.4 hours after). Approximately 4.4% of patients developed side effects to HL, including 2 patients with dystonia which improved with medication before discharge. Most patients (56.6%) were discharged home while 43.2% were admitted to hospital mostly because of refractory nausea or vomiting (70.1%). Receiving HL as the only medication in the ED led to lower hospital admission (odds ratio = 0.25, P < 0.05). Diabetes, cannabinoid use, anxiety, male sex, and longer ED stay were associated with increased hospital admissions. DISCUSSION: Most patients treated in our ED with HL for GI symptoms, particularly nausea, vomiting, and/or abdominal pain, were successfully treated and discharged home. HL use seemed relatively safe and, when used as the only medication, led to less frequent hospital admissions.

Surgical Treatment for Refractory Gastroparesis: Stimulator, Pyloric Surgery, or Both?

BACKGROUND: Several surgical options exist for refractory gastroparesis (Gp) including gastric electric stimulation (GES) and pyloric surgery (PS) such as pyloromyotomy or pyloroplasty. Few studies exist comparing the outcomes of these surgeries. AIM: Compare the clinical outcomes of GES, PS, and simultaneous GES+PS for refractory Gp. METHODS: Patients undergoing surgical intervention at our medical center from January 2016 to April 2019 were given pre- and post-surgery questionnaires to assess their response to intervention: Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM) grading symptoms and Clinical Patient Grading Assessment Scale (CPGAS) grading response to treatment. Results are expressed as mean ± SE. RESULTS: One hundred thirty-two patients underwent surgical intervention; 12 were excluded. Mean CPGAS improvement overall was 2.8 ± 0.2 (p < 0.01): GES+PS had CPGAS score at 3.6 ± 0.5, pyloric interventions 3.1 ± 0.5, and GES 2.5 ± 0.4 (p > 0.05). Mean improvement in Gastroparesis Cardinal Symptom Index (GCSI) total score was 1.0 ± 0.1 (p < 0.01), with improvement of 1.1 ± 0.2 for GES + PS, 0.9 ± 0.2 for GES, and 0.9 ± 0.2 for PS (p > 0.05). GES and GES + PS, but not PS only, significantly improved symptoms of nausea and vomiting (p < 0.01). Among gastroparesis subtypes, patients with diabetic gastroparesis had more improvement on nausea/vomiting subscale compared with idiopathic gastroparesis (p = 0.028). CONCLUSIONS: Patients with refractory symptoms of Gp undergoing GES, PS, or combined GES+PS each had significant improvement of their GCSI total score. GES and combined GES+PS significantly improved nausea/vomiting. These results suggest GES or combined GES+PS appears better for nausea/vomiting predominant refractory Gp.

Effectiveness of gastric electrical stimulation in gastroparesis: Results from a large prospectively collected database of national gastroparesis registries.

BACKGROUND: Gastric electrical stimulation (GES) for treating gastroparesis symptoms is controversial. METHODS: We studied 319 idiopathic or diabetic gastroparesis symptom patients from the Gastroparesis Clinical Research Consortium (GpCRC) observational studies: 238 without GES and 81 with GES. We assessed the effects of GES using change in GCSI total score and nausea/vomiting subscales between baseline and 48 weeks. We used propensity score methods to control for imbalances in patient characteristics between comparison groups. KEY RESULTS: GES patients were clinically worse (40% severe vs. 18% for non-GES; P < .001); worse PAGI-QOL (2.2. vs. 2.6; P = .003); and worse GCSI total scores (3.5 vs. 2.8; P < .001). We observed improvements in 48-week GCSI total scores for GES vs. non-GES: improvement by ≥ 1-point (RR = 1.63; 95% CI = (1.14, 2.33); P = .01) and change from enrollment (difference = -0.5 (-0.8, -0.3); P < .001). When adjusting for patient characteristics, symptom scores were smaller and not statistically significant: improvement by ≥ 1-point (RR = 1.29 (0.88, 1.90); P = .20) and change from the enrollment (difference = -0.3 (-0.6, 0.0); P = .07). Of the individual items, the nausea improved by ≥ 1 point (RR = 1.31 (1.03, 1.67); P = .04). Patients with GCSI score ≥ 3.0 tended to improve more than those with score < 3.0. (Adjusted P = 0.02). CONCLUSIONS AND INFERENCES: This multicenter study of gastroparesis patients found significant improvements in gastroparesis symptoms among GES patients. Accounting for imbalances in patient characteristics, only nausea remained significant. Patients with greater symptoms at baseline improved more after GES. A much larger sample of patients is needed to fully evaluate symptomatic responses and to identify patients likely to respond to GES.

Outcomes of surgical intervention for refractory gastroparesis: a systematic review.

BACKGROUND: Gastroparesis (GP) is characterized by delayed gastric emptying with symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Various surgical options exist to treat GP not responding to medical treatments (refractory GP), including gastric electric stimulation (GES), gastrectomy (GTx), and pyloric interventions (PI), whereas the outcomes of these procedures have been published; few comparison studies exist. METHODS: PubMed literature review for articles from September 1988 to October 2017 was performed for prospective and retrospective analyses reporting >5 patients. Unweighted (per study) and weighted (per patient) overall improvement and improvement in symptoms of nausea, vomiting, and abdominal pain were calculated and compared for the different procedures. RESULTS: Of 325 studies satisfying search criteria, 38 met the study criteria and were included for analysis. Total response to intervention, both weighted and unweighted, was greater with PIs compared to GES (P < 0.05). For unweighted symptom improvements, nausea improved more with PI than with GES (P < 0.05). GES improved vomiting more than epigastric pain (P < 0.05). For weighted symptom improvements, pyloric surgery and GTx improved vomiting compared to GES (P < 0.05). CONCLUSIONS: Published outcomes of GES, pyloric surgery, and GTx for refractory GP are compared. Pyloromyotomy/pyloroplasty improves patient response greater than with GES. Weighing by number of studies, pyloric surgery improves nausea and abdominal pain greater than GES. For GES, vomiting is more likely to improve than abdominal pain. Weighing by number of patients, pyloric surgery and GTx improved vomiting compared to GES.

Idiopathic gastroparesis.

Gastroparesis is a chronic symptomatic disorder of the stomach characterized by delayed emptying without evidence of mechanical obstruction. Idiopathic gastroparesis refers to gastroparesis of unknown cause not from diabetes; not from prior gastric surgery; not related to other endocrine, neurologic, rheumatologic causes of gastroparesis; and not related to medications that can delay gastric emptying. There is overlap in the symptoms of idiopathic gastroparesis and functional dyspepsia. Patients with idiopathic gastroparesis often have a constellation of symptoms including nausea, vomiting, early satiety, postprandial fullness, and upper abdominal pain. Current treatment options of dietary management, prokinetics agents, antiemetic agents, and symptom modulators do not adequately address clinical need for idiopathic gastroparesis.

Surgical outcomes after gastric electric stimulator placement for refractory gastroparesis.

BACKGROUND: Gastric electric stimulation (GES) is used for refractory gastroparesis symptoms. Although symptomatic improvement has been reported with GES, few studies describe the need for additional surgery after placement. Our goal was to evaluate the outcomes of a large series of GES at a single institution. METHODS: A retrospective review was performed for patients undergoing Enterra GES (Medtronic, Inc.) placement for refractory gastroparesis from October 2000 to October 2011. The main outcome measures were the need/indications for additional procedures and symptom improvement. RESULTS: A total of 266 patients had a GES implanted; 233 had complete records and were included in the analysis. Fifty-eight percent (n = 135) required an additional procedure after GES placement. Nutrition access (45 patients requiring 77 procedures) and subcutaneous pocket issues (n = 21) were the most common indications for subsequent procedures. Twelve percent (n = 29) had the GES explanted, mainly for continued gastroparetic symptoms (n = 11), mechanical issues (n = 9), or infection (n = 4). Ninety patients had subsequent hospitalizations, mainly for gastroparetic flares. Mortality during the follow-up period was 2.1 %. BMI was predictive of additional surgical procedure: when overweight, the risk of pocket revision increased 4.45 times (OR = 4.452). Of 74 most recent patients with prospective long-term outcome data, 70 % reported improved symptoms of pain, bloating, and nausea. CONCLUSIONS: Although most patients reported symptomatic improvement after GES implantation, there is often a need for additional surgical procedures as well as associated complications after GES placement. Additional procedures were most frequent for surgical nutrition and subcutaneous pocket issues; pocket revisions were more frequent in obese patients. From our results, we amended our practice to add a jejunostomy tube in malnourished patients and suture the stimulator to the subcutaneous pocket fascia. Further studies will determine if these changes reduce the rate of complications and additional procedures after GES placement.

Clinical guideline: management of gastroparesis.

This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.

Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis.

BACKGROUND & AIMS: Gastroparesis can lead to food aversion, poor oral intake, and subsequent malnutrition. We characterized dietary intake and nutritional deficiencies in patients with diabetic and idiopathic gastroparesis. METHODS: Patients with gastroparesis on oral intake (N = 305) were enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Registry and completed diet questionnaires at 7 centers. Medical history, gastroparesis symptoms, answers to the Block Food Frequency Questionnaire, and gastric emptying scintigraphy results were analyzed. RESULTS: Caloric intake averaged 1168 ± 801 kcal/day, amounting to 58% ± 39% of daily total energy requirements (TER). A total of 194 patients (64%) reported caloric-deficient diets, defined as <60% of estimated TER. Only 5 patients (2%) followed a diet suggested for patients with gastroparesis. Deficiencies were present in several vitamins and minerals; patients with idiopathic disorders were more likely to have diets with estimated deficiencies in vitamins A, B(6), C, K, iron, potassium, and zinc than diabetic patients. Only one-third of patients were taking multivitamin supplements. More severe symptoms (bloating and constipation) were characteristic of patients who reported an energy-deficient diet. Overall, 32% of patients had nutritional consultation after the onset of gastroparesis; consultation was more likely among patients with longer duration of symptoms and more hospitalizations and patients with diabetes. Multivariable logistic regression analysis indicated that nutritional consultation increased the chances that daily TER were met (odds ratio, 1.51; P = .08). CONCLUSIONS: Many patients with gastroparesis have diets deficient in calories, vitamins, and minerals. Nutritional consultation is obtained infrequently but is suggested for dietary therapy and to address nutritional deficiencies.

Predictive factors for clinical improvement with Enterra gastric electric stimulation treatment for refractory gastroparesis.

UNLABELLED: The objectives of this study were to determine the clinical response to Enterra gastric electric stimulation (GES) in patients with refractory gastroparesis and to determine factors associated with a favorable response. METHODS: This study was conducted in patients undergoing Enterra GES for refractory gastroparesis. Symptoms were scored before and after GES implantation using the Gastroparesis Cardinal Symptom Index (GCSI) with additional questions about abdominal pain and global clinical response. RESULTS: During an 18-month period, 29 patients underwent GES implantation. Follow-up data were available for 28 patients, with average follow-up of 148 days. At follow-up, 14 of 28 patients felt improved, 8 remained the same, and 6 worsened. The overall GCSI significantly decreased with improvement in the nausea/vomiting subscore and the post-prandial subscore, but no improvement in the bloating subscore or abdominal pain. The decrease in GCSI was greater for diabetic patients than idiopathic patients. Patients with main symptom of nausea/vomiting had a greater improvement than patients with the main symptom of abdominal pain. Patients taking narcotic analgesics at the time of implant had a poorer response compared to patients who were not. CONCLUSIONS: GES resulted in clinical improvement in 50% of patients with refractory gastroparesis. Three clinical parameters were associated with a favorable clinical response: (1) diabetic rather than idiopathic gastroparesis, (2) nausea/vomiting rather than abdominal pain as the primary symptom, and (3) independence from narcotic analgesics prior to stimulator implantation. Knowledge of these three factors may allow improved patient selection for GES.

Gastric electric stimulation for the treatment of gastroparesis.

Gastric electric stimulation is an emerging therapy for refractory gastroparesis. Several methods have been used to electrically stimulate the stomach. Initial studies used gastric electrical pacing, which entrains and paces the gastric slow waves at a slightly higher rate than the patient's normal myoelectric frequency of 3 cycles per minute (cpm). The technique currently practiced uses high-frequency, low-energy stimulation at four times the basal rate (12 cpm). Results from published studies with high-frequency stimulation reveal an improvement in symptoms, primarily of nausea and vomiting, and primarily in patients with diabetic gastroparesis, with only a modest change in gastric emptying. As treatment with gastric electric stimulation evolves, further delineation of its overall effectiveness, the type of patient that will likely respond, optimal electrode placement(s), and stimulus parameters should be explored.