Obstructive Gastroparesis: Patient Selection and Effect of Laparoscopic Pyloroplasty.

BACKGROUND: Functional obstructive gastroparesis is an understudied subtype of gastroparesis with normal 3 cycle per minute gastric myoelectrical activity that responds to botulinum toxin A injection and balloon dilation of the pylorus. AIMS: To determine the effect of pyloroplasty on symptoms, weight, gastric emptying, and gastric myoelectrical activity in patients with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity. METHODS: Ten patients (average age 36 years with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity) who had at least two successful endoscopic pyloric therapies and then underwent pyloroplasty were identified. Electrogastrography with water load satiety test was performed to determine gastric myoelectrical activity. Gastric emptying was measured with 4-h scintigraphy. KEY RESULTS: Six months after pyloroplasty, nine of ten patients reported improved symptoms and weight increased an average of 6.4 lb (p = 0.04). The average percentage of meal retained at 4 h decreased from 47% before to 16% after pyloroplasty (p < 0.01) and normalized in six patients. After pyloroplasty, the percent distribution of gastric myoelectrical activity power in the 3 cycle per minute range decreased at each measured interval compared with pre-pyloroplasty (p < 0.01). CONCLUSIONS: (1) Pyloroplasty in these patients with obstructive gastroparesis improved gastric emptying and decreased 3 cycle per minute gastric myoelectrical activity, consistent with relief of functional gastric outlet obstruction. (2) Pyloric neuromuscular dysfunction is a key factor in delayed emptying in patients with functional obstructive gastroparesis.

Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis.

Gastroparesis (GP) is associated with loss of interstitial cells of Cajal (ICCs) and gastric dysrhythmias such as tachygastria. We hypothesized that a subset of patients with GP, normal 3cycles per minute (cpm) gastric myoelectrical activity (GMA), and normal upper endoscopy may respond to pyloric therapies. AIMS: To determine the effect of botulinum toxin A (btA) injection or balloon dilation (BD) of the pylorus on symptoms and body weight in patients with GP and 3cpm GMA. METHODS: Patients were identified who had GP, normal 3cpm GMA, and normal endoscopy that excluded mechanical obstruction of the pylorus. Electrogastrograms (EGG) with water load tests (WLT) were recorded to determine GMA. Gastric emptying was measured with 4h scintigraphy. Each patient underwent up to three pyloric treatments with btA or BD. RESULTS: Thirty-three patients (29 women) with an average age of 42years were studied. Seventy-nine percent had idiopathic GP and 21% had diabetic GP. The average percent meal retained at 4h was 42% and each EGG test showed normal 3cpm GMA. Nausea was the major symptom in 76% of patients. Complete or partial symptom response occurred in 75%, 72%, and 88% of patients after the first, second, or third endoscopic pyloric treatment, respectively. Overall, 78% of the 33 patients reported improvement in symptoms and average weight gain was 1.54lb from baseline to final treatment (p<0.04). CONCLUSION: Pyloric therapies appear to be effective treatments in symptomatic patients with GP and 3cpm GMA and controlled trials are warranted.

Pancreatic Adenocarcinoma Invading the Duodenum and Presenting as Idiopathic Gastroparesis with Nausea and Vomiting.

A 65-year-old woman presented with a 5-month history of nausea, vomiting, and weight loss. Prior esophagogastrodudenoscopy showed retained food and delayed gastric emptying, but abdominal computed tomography was normal. The working diagnosis was idiopathic gastroparesis. Subsequently, an electrogastrogram test showed normal 3-cycle-per-minute activity, although it was suggestive of obstructive gastroparesis. Repeat esophagogastrodudenoscopy showed obstruction at the postbulbar duodenum. Repeat abdominal computed tomography revealed a 2.2 x 1.6-cm mass in the pancreaticoduodenal groove narrowing the descending duodenum and aspiration of the mass revealed adenocarcinoma.

Use of tryptophan-fortified hydrolyzed collagen for nutritional support.

Protein is essential for the maintenance of optimal health. Without adequate amounts of amino acids, organs become dysfunctional and ultimately death can result. Protein deficiency is a common problem in both adults and children. Numerous nutritional supplements have been developed to help optimize protein intake. The purpose of this paper is to describe the use of tryptophan-fortified hydrolyzed collagen for nutritional support in malnourished patients.