Mistakes in ... 2021 - 32

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Mistakes in... 2021
psychological causes. In patients who have
headaches or new neurological symptoms,
it is important to perform a neurological
examination, and cross-sectional imaging of
the brain may be warranted to exclude a
central lesion. Vomiting that is induced by
anxiety and stress is best managed with
psychotherapy (e.g. cognitive behavioural
therapy or mindfulness) or pharmacological
therapies (e.g. selective serotonin reuptake
inhibitors).
The final condition to consider is narcotic
bowel syndrome (also known as opiate-induced
central sensitisation syndrome), which is
caused by the side effects of opiates on the gut.
Typically, patients have worsening abdominal
pain, but they can also have nausea, vomiting
and epigastric bloating, which are symptoms
similar to that of gastroparesis. As gastric
emptying is delayed by opiates, it is useful to
reassess symptoms and gastric emptying in
patients once they have been weaned off them
(see mistake 6).
Mistake 3 Failing to investigate
biopsychosocial factors in patients with
gastroparesis
It is important to remember that in patients
who have gastroparesis, there is no correlation
between the severity of symptoms and the
severity of disease.6
In fact, the symptoms are
not necessarily related to the delayed gastric
emptying alone but arise due to a complex
interplay between abnormal physiology (e.g.
delayed gastric emptying or possible visceral
hypersensitivity) and psychosocial factors
such as poor sleep, low mood, stress, and
poor diet.
It is therefore important for the successful
management of gastroparesis to use a
biopsychosocial approach and ask about these
factors and manage them rather than simply
targeting the delayed gastric emptying with
prokinetics, pyloric Botox or more invasive
therapies such as gastric peroral endoscopic
myotomy and gastric pacing. It is also important
to consider the role that visceral hypersensitivity
has to play, as it will cause nutrient intolerance
and pain even with post-pyloric feeding (e.g.
nasojejunal feeding) and will need to be treated
with neuromodulators.
Mistake 4 Ineffectively addressing
nutritional issues in patients with
gastroparesis
Foods that are high in fibre and fat are emptied
from the stomach more slowly, so patients with
gastroparesis should be advised to stick to a
low-fibre, low-fat diet and to eat little and often.
Liquids are easier to tolerate, so patients who
continue to have difficulty consuming solids can
20
be moved onto a liquid diet or a small-particle diet
(i.e. foods that can be mashed with a fork). One
randomised controlled trial found that a 20-week
dietary intervention with a small-particle diet was
associated with an improvement in the symptoms
of nausea, vomiting, early satiety, postprandial
fullness, heartburn and regurgitation compared
with a low glycaemic index diet.7
However, neither
the small-particle diet nor the low glycaemic index
diet had any effect on upper abdominal pain.7
The complications of gastroparesis include
dehydration as well as electrolyte and nutritional
deficiencies, which are secondary to the
vomiting. Weight loss is rare but is present in
about 8% of patients, usually those with a severe
delay in gastric emptying. Enteral nutrition may
be needed in patients who have nutritional
deficiencies and weight loss, and it is important
that such patients are assessed by a dietician.
Nutritional treatment can start with oral liquid
supplements, but if patients continue to vomit
and have associated weight loss, despite
optimising the use of prokinetics, they may
need post-pyloric feeding. If patients do not
tolerate post-pyloric feeding (i.e. they have
ongoing vomiting), this would suggest that it is not
the delay in gastric emptying that is the problem
but, instead, that they may have a problem with
visceral hypersensitivity and that this should
be the target of treatment. Pain is not a clear
indication of a requirement for jejunal feeding
and if patients are overweight and do not
have significant weight loss or nutritional
deficiencies, then jejunal feeding may not be
needed.8
As weight loss is rare and usually
associated with severe delays in gastric
emptying, it is important to consider other factors
that may be contributing to vomiting in patients
with weight loss and only mild to moderate
delays in gastric emptying (e.g. eating disorders).
Mistake 5 Not optimising the medications
for gastroparesis
It is important to optimise the medications used to
treat patients with gastroparesis, whilst avoiding
the following mistakes.
Firstly, for prokinetics to work most effectively,
they need to be taken half an hour before meals to
induce gastric motility. Patients therefore need to
be educated about this.
Erythromycin is a motilin-receptor agonist and
an effective prokinetic, but it should not be used
for too long. In a randomised control study
of metoclopramide 10 mg three times a day
versus erythromycin 250 mg three times a day in
patients with delayed gastric emptying, there
was a reduction in symptoms and in the gastric
emptying time for both groups, but there was
better symptomatic improvement in the
erythromycin group.9
However, erythromycin is
associated with tachyphylaxis, which means that
its use should be limited to a few weeks. For acute
flares, it can be used as an add-on to existing
treatments, after which time it should be stopped.
Serotonergic agents (e.g. prucalopride)
should also be considered for the treatment of
gastroparesis. Prucalopride is an agonist of the
5-HT4
(5-hydroxytryptamine 4) receptor and it
works to improve gastrointestinal transit. It is
typically used to treat slow-transit constipation
in females but also helps to speed up gastric
emptying. In a randomised placebo-controlled
trial of prucalopride versus placebo in patients
with idiopathic gastroparesis, 4 weeks of
prucalopride led to improved gastric emptying,
reduced symptoms and better quality of life.10
The usual dose is 2 mg once a day and it can be
increased to 4 mg once a day, although higher
doses are associated with more side effects
(e.g. headaches and diarrhoea). It can be helpful
to trial prucalopride in patients who do not
respond to first-line treatment, particularly if
they also suffer with constipation (e.g. in
patients with scleroderma or other connective
tissue disorders who have upper and lower
gastrointestinal hypomotility with
slow-transit constipation and delayed gastric
emptying).
It is also important to consider the potential
serious side effects of prokinetic medications.
Metoclopromide is associated with
extrapyramidal side effects, such as dystonia
and akathisia after a single dose or tardive
dyskinesia and Parkinsonism after prolonged
doses. Therefore, metoclopramide should not be
prescribed in the long term. If patients respond
symptomatically to metoclopramide, it is helpful
to convert them to another prokinetic to be used
more long term. Domperidone is an option that is
not associated with extrapyramidal side effects.
However, domperidone is associated with a
prolonged QT interval, so it is imperative
that patients have an ECG to check for a
normal QT interval before initiation of treatment
- the ECG should be repeated once patients
have been started on domperidone to ensure
that the QT interval remains in the normal range.
Mistake 6 Ignoring the role of drugs such
as opiates in generating symptoms
Opiates cause delayed gastric emptying and
symptoms of gastroparesis, so it is hard to
interpret the clinical picture in patients on
opiates. In a study of 223 patients with a diagnosis
of gastroparesis, 20% were on regular opiates and
10% were on opiates on an as-required basis.11
The
median morphine equivalent was 60 mg per day.
Patients on opiates had more intense and longer
lasting nausea, more frequent and severe
vomiting, more retching, more heartburn,
increased chest discomfort, more upper abdominal
pain and increased hospitalizations than patients
who were not taking opiates.11
Therefore, in
patients with suspected gastroparesis and opiate
Mistakes in ... 2021

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