Management of Refractory Gastroparesis in Older People

Introduction

Gastroparesis is a medical condition characterized by partial paralysis of the stomach resulting in the stomach being unable to empty itself of food in the normal way. This results in the food remaining in the stomach for an abnormally long time. Gastroparesis can cause serious complications such as severe dehydration and malnutrition, food that sits in the stomach for a long time can ferment, leading to the growth of bacteria. Undigested food in the bacteria can harden into a solid mass called a bezoar. Bezoar can cause blockages in the stomach preventing food from passing into the small intestine. This can cause nausea and vomiting and may be life-threatening, and decreases the quality of life. The incidence of gastroparesis increases with age. Gastroparesis in the older population is mostly due to complications of diabetes or neurologic conditions like Parkinson’s disease.

What Are the Etiologies of Gastroparesis?

The exact cause of gastroparesis is unknown, but in many cases, it can be due to damage to the vagus nerve - a nerve that controls the vagus nerve. Damage to the vagus nerve can be caused due to certain diseases or conditions, such as

• Diabetes.

• Viral infections.

• Certain medications like antidepressants.

• Post-surgical complication.

• Post-gastroenteritis.

• Neurologic diseases.

• Connective tissue diseases.

• Parkinson’s disease.

• Multiple sclerosis.

• Amyloidosis.

• Scleroderma.

• Cancer.

• Hypothyroidism.

• Radiation therapy.

What Is the Pathophysiology of Gastroparesis?

The pathophysiology of gastroparesis is not completely understood. Decreased motility in the duodenum can be contributing factor too. However, most time, cases are related to an impairment of the stomach’s capacity to

• Relax so that it can receive food in the fundus.

• Contract to grind and mix food in the antrum.

• Relax the pyloric sphincter to allow emptying into the small intestine.

What Are the Signs and Symptoms of Gastroparesis?

Some of the signs and symptoms of gastroparesis are as follows

• Nausea and vomiting.

• Weight loss.

• Abdominal pain.

• Acid reflux.

• Lack of appetite.

• Abdominal bloating.

• A feeling of fullness after eating a few bites.

• Changes in blood sugar level.

• Heartburn.

What Are the Effects of Aging on Gastric Motility?

In general, gastric motility is relatively preserved during healthy aging. Healthy aging is associated with minimal slowing of gastric emptying, less hunger, delayed proximal gastric accommodation, and an increase in the postprandial antral volume. Thus older adults may experience less fullness, discomfort, and bloating in response to proximal gastric distention when compared with young people. The mechanisms underlying the slowing of gastric emptying with aging are uncertain. Autonomic nerve dysfunction is more common in older people, but its correlation with slower gastric emptying is poor, and it remains unclear if there is a derangement of gastric electrical rhythm with aging. Neurohumoral changes such as increased plasma cholecystokinin, CCK (both fasting and postprandial), decreased plasma ghrelin (hunger hormone), and decreased mucosal prostaglandins, pepsin, and bicarbonate levels have been reported in the elderly, which may affect gastric motility and digestive function. A decrease in gastric acid secretion associated with aging may decrease the efficiency of trituration of solids and hence will mildly and subtly slow gastric emptying.

How Is Gastroparesis Diagnosed?

To make a diagnosis, a doctor may carry out the following tests

1. Upper Gastrointestinal Endoscopy - To visually examine the upper digestive system, such as the esophagus, stomach, and duodenum, and the beginning of the small intestine.

2. Gastric Emptying Scan - It involves eating food that contains small amounts of radioactive substances. A scan will detect the movement of the food in the patient’s abdomen to monitor the rate at which food leaves the stomach. If the scan shows more than 10 percent of the food is still in the stomach four hours after eating, that is indicative of gastroparesis.

3. Ultrasound - To create pictures of the body organs.

4. Upper Gastrointestinal Body Series - The patient is asked to take a white chalky liquid that coats the esophagus, stomach, and small intestine that shows up on the X-ray.

What Is the Differential Diagnosis of Gastroparesis in Older People?

In gastroparesis, vomiting must be differentiated from regurgitation due to reflux disease or rumination syndrome, vomiting syndrome, and abdominal pain with vomiting in superior mesenteric artery syndrome. Vomiting typically occurs one or two hours or longer following the meal, with older food contents being identified. The symptomatic spectrum of small intestinal bacterial overgrowth (SIBO) and gastroparesis overlap significantly. Patients may have both bloating, early satiety, and upper abdominal discomfort. The two disorders can coexist in the older population due to hypoacidity promoting bacterial colonization of the small bowel.

How Is Gastroparesis Treated?

Gastroparesis is a long last condition, and treatment does not usually cure the disease. Dietary changes and medications can help control the condition. The doctor may need to treat the underlying condition or perform laparoscopic procedures if dietary and lifestyle changes do not resolve the issue.

How to Manage Gastroparesis in Older People?

The following methods should be adopted to manage gastroparesis in older patients:

• The first modality of treatment for all patients is dietary changes. Frequent small meals with snacks are recommended over large meals.

• A low-fat diet is beneficial since fat slows down gastrointestinal motility.

• Limit ‘roughage’ and high-fiber food.

• Consider homogenization of food.

• Eating well-cooked and fresh fruits and vegetables instead of raw fruits and vegetables.

• For patients at risk of malnutrition, vitamin supplementation may be necessary.

• Drinking plenty of water.

• If dietary changes are insufficient to manage symptoms, medications may be necessary.

• For patients with acute exacerbations with gastroparesis that are refractory to dietary changes in oral medications, a hospital admission may be necessary for intravenous fluids, medications, and in some cases, intravenous nutrition.

• For patients with long-term refractory symptoms, those who have been repeatedly hospitalized, interventions like a percutaneous endoscopic gastrotomy tube to vent the gastric contents during an exacerbation or a jejunal feeding tube, laparoscopic pyloroplasty and a procedure called G-POEM (gastric peroral endoscopic myotomy) are used.

• Avoid carbonated beverages, smoking, and alcohol.

Conclusion

Proper dietary changes and, in a few cases medications can help the majority of patients live a normal life. However, a small but notable minority of patients will have profound symptoms resulting in malnutrition and frequent hospital admissions. In certain cases, surgical interventions can be administered. Gastroparesis can be a painful condition, and it is more discomforting for older people; hence proper management should be done in this population.