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Gastroparesis: Dangers of a “Slow Stomach”

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Date: November 1, 2013      Publication: Bottom Line Health      Source: Gerard Mullin      Print:

It’s often overlooked and can lead to bloating, abdominal pain and other troubles.

When you eat a meal, you probably don’t think about the amount of time it takes your body to digest the food. But for many people, this is the key to uncovering a host of digestive ills—and even some seemingly unrelated concerns such as chronic fatigue.

WHEN FOOD MOVES TOO SLOWLY

In healthy adults, digestion time varies, but it generally takes about four hours for a meal to leave the stomach before passing on to the small intestine and colon.

What happens: When food enters the stomach, signals from hormones and nerve cells trigger stomach acid, digestive enzymes and wavelike peristaltic contractions of the muscles in the stomach wall. Together, they break down the meal into a soupy mixture called chyme, which peristalsis then pushes into the small intestine.

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This process is known as gastric motility. And when gastric motility is impeded—when stomach emptying slows to a crawl, even though nothing is blocking the stomach outlet—it’s called gastroparesis.

Surprising fact: An estimated one out of every 55 Americans suffers from gastroparesis—but the condition is diagnosed in only one out of every 90 people who have it.

When gastroparesis goes undetected: The symptoms of gastroparesis often are obvious—for example, nausea, vomiting, feeling full right after starting to eat a meal, bloating and abdominal pain. But the condition can cause other health problems such as unwanted weight loss and even malnutrition. It also can interfere with the absorption of medications and wear you down physically (one study found that 93% of people with gastroparesis were fatigued).

GETTING THE RIGHT DIAGNOSIS

If you’re experiencing the symptoms of gastroparesis, see your primary care physician. He/she may refer you to a gastroenterologist. It’s likely the specialist will order the “gold standard” for diagnosing gastroparesis, a test called gastric emptying scintigraphy.

Next step: At the test, you’ll eat a meal that contains radioactive isotopes. (Radiolabeled Egg Beaters with jam, toast and water are typical.) A scan is taken at one, two and four hours after the meal with a scintigraph, or gamma camera. A one-hour scan after drinking liquid also is recommended. If images from any of the scans show that your stomach isn’t emptying normally, you are diagnosed with gastroparesis.

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Another approach: When I perform an endoscopy on a patient with gastroparesis-like symptoms (a thin, flexible tube with a light and camera on the end is inserted down the esophagus and into the stomach), if I see a significant amount of retained fluids or food despite an overnight fast, I make the diagnosis then and there, saving time and money.

FINDING THE CAUSE

Experts haven’t discovered the exact mechanisms underlying gastroparesis. In fact, an estimated 40% of cases are idiopathic—the cause is unknown. Gastroparesis is a complication for about 30% of people with type 1 or type 2 diabetes. What happens: Diabetes can damage the vagus nerve, which runs from the cranium to the abdomen and plays a key role in digestion.

Medication also can cause gastroparesis. Examples: Narcotic pain relievers, such as oxycodone (OxyContin), and anticholinergics, a class of drugs that includes certain antihistamines and overactive bladder medications.

Small intestine bacterial overgrowth, in which abnormally large numbers of bacteria grow in the small intestine, also can lead to gastroparesis.

GETTING THE BEST MEDICAL CARE

I have found that an integrative approach that combines conventional and alternative medicine is the best way to control gastroparesis.

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Conventional treatment typically includes medications that either speed stomach emptying or help control the symptoms of gastroparesis such as nausea and vomiting. For example…

  • Metoclopramide (Reglan). This is currently the only FDA-approved medication for gastroparesis. Reglan works by blocking receptors of the neurotransmitter dopamine, which accelerates gastric motility.

Problem: The FDA has approved Reglan for no more than 12 weeks of use because long-term intake can cause tardive dyskinesia—involuntary, repetitive body movements, such as grimacing. Because of this risk, I rarely prescribe metoclopramide for my patients.

Another medication option: The drug domperidone has the same dopamine-suppressing action in the digestive tract as Reglan, but it does not cross the blood-brain barrier and, therefore, is much less likely to cause tardive dyskinesia. Risks include breast tenderness and worsening of the heart condition Long QT Syndrome.

However, according to clinical guidelines for the management of gastroparesis published in The American Journal of Gastroenterology, domperidone “is generally as effective” as metoclopramide with “lower risk of adverse effects.”

Domperidone is readily available in most countries, where it is a standard treatment for heartburn, but not in the US. However, your doctor can obtain it under the FDA’s Investigational New Drug program.

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  • Antinausea drugs. Prochlorperazine (Compazine) and ondansetron (Zofran) are commonly prescribed for gastroparesis.
  • Botox. Injections of botulinum toxin into the pylorus (the opening from the stomach into the small intestine) can help some patients for four to six months, after which the injection must be repeated.

New approaches: Physicians at Johns Hopkins are now using a new and effective procedure called through-the-scope transpyloric stent placement. With this procedure, an endoscope is used to place a stent (tube) that helps transfer stomach contents into the small intestine.

Another new approach, pioneered by John Clarke, MD, of Johns Hopkins, involves placing a stent across the pylorus to drain the stomach.

ALTERNATIVE THERAPIES

Certain alternative therapies may also help with stomach motility and/or with nausea and vomiting…*

  • Peppermint oil. This can help gastroparesis, but it also can worsen heartburn in people with gastroesophageal reflux disease (GERD). If you have gastroparesis but not GERD, an enteric-coated softgel of peppermint oil may help you. Recommended dose: 90 mg once a day.
  • Iberogast. This pharmaceutical-grade, multiherbal tincture can help with gastroparesis, studies have shown. Recommended dose: 20 drops, two to three times a day, before meals. (Iberogast does contain alcohol.)
  • Ginger. Gingerroot may help with nausea and improve gastric motility. Recommended dose: 1,200 mg daily.
  • Acupuncture. This treatment can help control the symptoms of gastroparesis. Acupuncture has been shown to be effective for nausea and vomiting and abdominal pain and bloating.

Diet/Lifestyle Tips

Many dietary and lifestyle habits can improve stomach motility…

  • Eat smaller, more frequent meals. Eat smaller amounts of food every two, three or four hours.
  • Reduce dietary fiber and fat. Both slow stomach emptying.
  • Chew food thoroughly.
  • Chew sugarless gum. Do so for about one hour after eating to stimulate peristalsis.
  • Take a leisurely five- or 10-minute (or longer) walk after every meal.

*Be sure to check with your doctor before trying these therapies, which are available online and at most health-food stores.

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Source: Gerard Mullin, MD, an associate professor of medicine at The Johns Hopkins University School of Medicine and director of the Celiac Disease Clinic, Integrative GI Nutrition Services and the Capsule Endoscopy Program at Johns Hopkins Hospital, all in Baltimore. He is the author of The Inside Tract, editor of Integrative Gastroenterology and several other textbooks, and the author or coauthor of more than 50 scientific papers.