Selecting a Treatment Regimen
ÎManagement of gastroparesis focuses on alleviation of symptoms and improvement of delayed gastric emptying. The recommended course of treatment depends on symptom severity.
• Gastroparesis with mild, easily managed symptoms may be controlled with dietary modification.
• Severe instances of gastroparesis may require surgical intervention, nutritional support, or both.
• More persistent gastroparesis with moderate symptoms typically requires pharmacologic intervention (prokinetics, antiemetics, analgesics), with the prokinetic metoclopramide recommended as first-line treatment.
ÎA low fat, low fiber diet of small portions and frequent feedings are often recommended.
ÎPatients are also advised to chew foods well and consider blenderizing meals if necessary since the antrum's grinding capability is reduced. Also, gastric emptying of liquids is relatively preserved even in gastroparesis. Medications should be administered as suspensions if available.
ÎPatients should remain upright after eating so gravity can assist food passage.
ÎTreatment has several goals: restoration of hydration, nutrition (enteral route being preferable), correction of electrolyte and glycemic imbalances, reducing vomiting with antiemetic agents, enhancing gastric emptying with prokinetic agents, and pain relief without narcotics.
ÎInitial treatment of diabetic gastroparesis should focus on blood glucose control.
ÎOpiates and drugs with anticholinergic potential that may further decrease gastric emptying should be reduced or withdrawn.
ÎExenatide, a mimetic of GLP-I used in treatment of type II diabetes, delays gastric emptying.
ÎIn contrast, inhibitors of the enzyme dipeptidyl peptidase 4 (DPP-4), which break down GLP-I, do not delay gastric emptying nor reduce food intake.
ÎErythromycin, besides being an antibiotic, is a motilin receptor agonist and the most effective IV prokinetic agent. (Unfortunately, erythromycin is associated with tachyphylaxis after about 4 weeks of oral treatment.)
ÎTotal parenteral nutriton should be reserved only for those patients who have failed an enteral feeding trial with several formulas. Complications of TPN include infection and thrombosis.
