Scott Webb (Host): Gastroparesis is a fairly common syndrome that occurs when our stomachs lose the ability to empty solid foods efficiently. Symptoms include nausea, vomiting, decreased appetite, and sometimes pain. My guest is here to tell us more about this syndrome and the various treatment options, including the GPOEM procedure, which is bringing relief to many patients.

I'm joined today by Dr. Mohammad Arfeen. He's Board Certified in Interventional Gastroenterology and Internal Medicine, and he practices at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb.

Doctor, it's nice to have you here today. I don't know a lot about gastroparesis, but you do. That's why you're here. You're the expert. So let's talk gastroparesis. What is that? Sort of give us a foundation, if you will.

Mohammad Arfeen, DO: Gastroparesis, is a chronic syndrome of the stomach. It's symptoms associated with delayed emptying of the stomach of solid food. So some people for various reasons, whether it's medications, whether it's diabetes that they've had for many years, surgeries, lose the ability to empty their stomach as efficiently as they should. And that retention of food in the stomach over time can cause symptoms such as nausea and vomiting, you know, decreased appetite because they feel full all the time. It's pretty much the mechanism by which these new injectable weight loss medications work, right?

They delay the gastric emptying so they get the same symptoms when they're on those medications, nausea and vomiting. So some people can develop that without those medications.

Host: Interesting. Yeah. So I'm wondering how you diagnose? Is it patient history, that kind of thing? Are there any tests involved?

Mohammad Arfeen, DO: Yeah. So the patient's history and their symptoms will definitely give us clues as to whether or not we're going down that path or whether we're considering that as a potential diagnosis. The formal diagnosis is made with something that's called a gastric emptying studies. It's a pretty cool test. They have you eat some radioactive scrambled eggs. And then they take an x-ray, pretty much every hour or so for four hours to measure how fast it leaves the stomach.

Host: I, I love learning new things, Doctor. And just that phrase, radioactive scrambled eggs. That's not one I've heard before, maybe on Star Trek or something. But that is really cool. And you got into it a little bit earlier about how some of these other diseases like diabetes, things like that, maybe we can drill down a little bit. Other diseases, conditions that trigger gastroparesis.

Mohammad Arfeen, DO: Yeah. So by far the most common cause is diabetic gastroparesis, and that's related to neuropathy. So, just like people get numbness and tingling in their hands and feet from the elevated blood sugars attacking the nerves over time, you can have the sugars attack or attach to the nerves that control the motility of the stomach.

So that same neuropathy or damage to the nerves can lead to decreased motility of the stomach and it's emptying function, and then spasm of the pylorus or the ring that is at the, outlet or the exit of the stomach.

Host: Sure. Yeah, this sounds like one of those things that probably really affects quality of life, right? Something that's, uh, you know, every meal, every day kind of thing. Maybe you can give us a sense of how it really affects patients.

Mohammad Arfeen, DO: Yeah. So it definitely is something that affects quality of life significantly for a lot of patients. The severity of symptoms varies. Some patients will have it, certainly with every meal, constantly. And it's just kinda like, you know, the nausea is persistent all the time. The vomiting, you know, multiple times a day, et cetera.

Other patients, it depends on when they eat or what they eat, then it's, it's intermittent. So there is certainly a, a wide degree of severity and of symptoms as well. There's a wide degree of symptoms that people can have just beyond nausea, vomiting. A lot of people will have pain and some people will have that just constant feeling of fullness or bloating. So there's a wide variety of symptoms and severity of symptoms.

Host: Yeah, I find there's a lot of mirroring of signs and symptoms between different conditions and things, and it's why we really need the experts to help us diagnose and treat, and let's talk about that. Let's talk about the treatment options for gastroparesis and what happens if it goes untreated. Sounds like it just really can ruin someone's life, but could it be worse than just having bad days?

Mohammad Arfeen, DO: Yeah, I think, I mean, mostly if it goes untreated, the issues you run into are with nutrition and maintaining weight and quality of life, and the psychosocial component of just having that negative impact on the quality of life. When if you're feeling bloated and nauseous all the time, it's obviously going to have an impact on your mood and your interactions with other people and your ability to function, et cetera.

That is certainly what happens when it goes untreated. And then obviously nutritional deficiencies, weight loss, muscle loss, osteoporosis, all those things can happen as a result of just not having the appropriate nutritional intake you need. The treatment, generally we start, we start fairly conservatively for most patients.

So if it's diabetic gastroparesis, then first step's, obviously getting the blood sugars under control, getting the diabetes under control. And then dietary modifications. So we know that the stomach is taking longer to empty than it should. So instead of doing larger meals a few times a day, we go to, instead of like three large meals a day, for instance, we'll go to six or seven small meals and be like, yeah, you can eat about a fist worth of food every three hours, as opposed to, you know, a large plate of food at breakfast, lunch, and dinner.

And for the majority of people, that helps them significantly. And then there are certain medications we can use to help kind of stimulate gastric motility. None of them are a great option, very long-term because they do come with their own side effects, but it, they're very helpful in, in times of flare when the symptoms are acutely worse, to get people through a couple of weeks of worse than usual symptoms and back into their kind of normal state.

Host: Yeah. Yeah. As you say, you start conservatively and then work your way up. So let's get to the working your way up part of it and have you describe the GPOEM procedure in detail if you can.

Mohammad Arfeen, DO: Yeah, so once someone is deemed kind of medically refractory, right, so they've, they've tried all the conservative therapies, diet modification, medications, controlling blood sugar, all of those things. And they're still having very significant symptoms, for a lot of these the symptoms that respond the best are nausea, vomiting, and bloating.

Usually not pain, unfortunately. Then we start getting kind of a little bit off the beaten path into the more invasive procedures. And one of them is the GPOEM and stands for Gastric Peroral Endoscopic Myotomy, or Pylori Myotomy. Functionally what we're doing is we're making a tunnel between the layers of the wall of the stomach. So we tunnel, through the gastric wall, like, you know, like it's sheets of toilet paper.

 So between the two ply, we're kind of forming a tunnel until we get to the ring of the Pylorus or the gastric outlet. So this is at the end of the stomach, there's a ring of muscle. We call that the pylorus. And then we can cut that ring from within the tunnel. And then when we close the tunnel, the stomach is sealed again.

And the hope is that by doing that we increase gastric emptying by removing if there's any component of spasm of that muscular ring that's preventing gastric emptying. So that, that's definitely one of the invasive procedures we can do in the appropriately selected patients. It does provide quite a bit of benefit, but it is again one of those treatments where you get to it when you've gone through all of the conservative steps and everything and haven't found a good solution.

Host: Right. Yeah. I'm sure most folks would like to avoid the GPOEM procedure if they can, and hope that those conservative measures and therapies work. But who's the right candidate, who's the best candidate for this procedure?

Mohammad Arfeen, DO: It varies from patient to patient, but the general patient that I look at is someone whose symptoms are primarily nausea and vomiting and bloating, not pain. Someone that's tried kind of all of the earlier steps as far as the conservative management and has had little to no improvement.

And then there's a couple other kind of intermediate procedures/ things we can try such as dilating the that pyloric ring or using a balloon to stretch it out or injecting Botox around it. Sometimes those procedures, although temporary, both of those, whether you use a balloon to stretch out the pylorus or you inject Botox to paralyze it, both of them have a temporary response, but sometimes response there can help guide us, like patients that respond to those can sometimes be more likely to respond to a GPOEM as well.

And then there's a newer test, we offer as well, that's called the EndoFLIP, where there's a, a balloon we can inflate in the Pylorus. And the balloon has pressure sensors within it. So on a, on a screen, we can actually see it squeeze in real time and see how tight it gets and how high the pressures get when it's squeezing.

And that's a newer space. The data's still kind of being firmed up, but some of the preliminary studies and papers have shown that based on that data, we can get a pretty good idea of people who are likely to respond to GPOEM. So if that's called an EndoFLIP procedure.

Host: Okay. Yeah, I referenced Star Trek earlier and it, it just feels like much of what you're describing is science fiction, but apparently it's not. Apparently it's real. You're doing this on human beings and it's amazing. Are there any side effects of the GPOEM procedure?

Mohammad Arfeen, DO: Yeah, so the main concerns intraprocedurally as far as complications, perforation, making a hole, bleeding, infection, all of that's pretty rare, less than 10% of the time. And most of the time if there is any complication, it can be handled immediately endoscopically. The largest concern after the procedure is typically non-response.

 Like I said, it's when you get to this point, it's kind of a procedure of later resort. So the efficacy is about 60 to 70% depending on who you read, but that still leaves a not insignificant portion of people that won't respond. So 30 to 40% of people will have little to no response. So that's something we definitely counsel patients on ahead of time.

And then from the patients that do respond, a small percentage of them, very, very small, can kind of over respond in a way where they'll develop a, a dumping syndrome type, phenomenon where their stomach empties too fast, so they may develop kind of issues with that. That's pretty rare though.

You don't see that very commonly. It's been written about, but, I haven't seen it too often in, in practice.

Host: Sure. Yeah. A, as you say, it's not an insignificant amount of people who just may not benefit from this at all, and they've already tried everything else, and that sounds unpleasant, of course. And maybe there's, there'll be more options, more studies and trials and things going on that'll help folks in the future. Just give you a chance here at the end. Final thoughts, takeaways. Sounds like there's a fair number of folks, Doctor in the world who are suffering from this and perhaps not seeking assistance from a medical professional, an expert like yourself. So what would be your best advice?

Mohammad Arfeen, DO: I think it's definitely something where if you have the diagnosis and it's something you're struggling with, it's worth seeing a gastroenterologist, making sure you're optimized on the appropriate medical therapy and, and you've had the appropriate dietary and lifestyle counseling.

And if you've gone through that route and you're not having symptom relief, there are other options out there. GPOEM's one of them. Obviously we talked about Botox injections and dilations briefly. There's these gastric stimulators which can be implanted, kind of like a pacemaker for the stomach almost.

So there's, there's other options available, outside of a feeding tube. And ultimately, you know, a small percentage of people will end up at the point where that is what they'll end up needing is a feeding tube. But what we've noticed is with a lot of these kind of other procedures, we're able to shift a large portion of people off that path to a feeding tube.

Host: Yeah.

Mohammad Arfeen, DO: And kind of give them enough relief to where they can function and maintain nutrition without that.

Host: Right. Yeah, it definitely sounds like there's room for optimism if folks are suffering from this, and I can't speak for listeners, but I feel like I've learned a lot today. So I appreciate your time and your expertise. Thank you so much.

Mohammad Arfeen, DO: Yep. Thank you.

Host: And for more information, visit franciscanhealth.org and search gastroparesis.

 And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.