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Maggie McKay (Host): Gastroparesis. Have you ever heard of it? It's a condition that affects the stomach muscles and can affect your digestion among other things. Joining us today, to tell us about Gastroparesis Combined Management by Gastroenterology and Surgery, are Dr. Joseph Sujka. He is Faculty at the University of South Florida, and Dr. Camille Thelin, also Faculty at University of South Florida in the Division of Gastroenterology and the USF GI Fellowship Program Director, and Women's GI Clinic Director.

Maggie McKay (Host): Welcome to MD cast by Tampa general hospital, a go-to listening location for a specialized position to physician content and a valuable learning tool for world-class health.

I'm your host, Maggie McKay. Thank you for being here to help us understand more about gastroparesis Doctors. To begin who gets gastroparesis and how do you start the workup of a patient with gastroparesis?

Camille Thelin, MD, MS (Guest): So, gastroparesis like you said, Maggie, is an upper GI motility disorder that's diagnosed subjectively by delayed gastric emptying. And it's really in the absence of mechanical obstruction. And multiple conditions have been associated with this syndrome that's characterized by symptoms like nausea and vomiting, early satiety, belching, bloating, and, and more specifically also, abdominal pain. The majority of cases are actually idiopathic, but there are associations with diabetic and iatrogenic. So like medicine induced cases, post-surgical, post viral. And even recently there's been a lot of push looking at auto-immune gastroparesis and there is even a panel of antibodies that have been discovered and are being tested at Mayo and the Cleveland Clinic and auto-immune disorders that are linked to gastroparesis developing.

Host: That sounds very uncomfortable. How would you know if you had it?

Dr. Thelin: So like I said, gastroparesis is a motility disorder that's diagnosed subjectively. So what can happen a lot of the times, and you make an interesting point in asking about workup, is that the diagnosis is made specifically based on clinical symptoms. And actually there was a recent epidemiology study, that is a population-based survey that looked at almost 44 million people, published in 2020. And it looked at medical records from 1999 to 2004, and they identified a prevalence of .16%. And that meant about 70,000 people. The interesting thing about the diagnosis is that the majority of these patients didn't have any type of actual diagnostic testing for this.

It was made based on clinical symptomology and their clinical comorbidities. So, I think one of the points that both Joe and I would like to make is that while there can be suspicion based on clinical symptomology and a medical history with one of those medical co-morbidities that I might have mentioned, we really want to stress that there needs to be further testing, like endoscopy to rule out a mechanical obstruction, although you could use any other type of testing, like an upper GI series, a small bowel follow through, or maybe an enterography to look at there isn't an obstruction as the cause of the symptoms and then also some type of testing and that the testing for would that, I mean, specifically is some type of testing objectively of the gastric emptying. So, that could be scintigraphy, which is really cost-effective and widely available. It's a radiology examination where the gastric emptying is measured at hour 1, 2, 3, and four after having eaten some type of what's considered fat, heavy fat content, heavy caloric intake meal, because those are things that the stomach has a longer time span to homogenize and turn into clime, and then expel out into the small bowel.

And you could also consider if scintigraphy is not available, to use something like a wireless motility capsule testing, which some centers are specializing in. And actually USF is working on acquiring this technology for this area in Florida. And here the, the benefit is that actually you have no radiology examination. And so you do not expose the patient to x-ray and you get information on small bowel, colonic and total gastric time and total GI transit time overall. can also think about doing breath testing. This is really more for research purposes, but it is used in certain centers and again, they eat a solid meal, then they expire CO2 that's got a radio isotope that's labeled there. They measure it in a mass spectrometer or some type of expiratory concentration field unit and they again, avoid radiation in this setting. And then they look to see how much of that. And it's supposed to tell you what's the delay in the gastric emptying at certain timeframes.

Host: Okay. So, Dr. Sujka, what sort of changes once the diagnosis is made, does the patient need to make prior to medication to improve their symptom profile?

Joseph Sujka, MD (Guest): Yeah, I'd like to add, I think that Camille did a great job of laying out all the different things that can cause gastroparesis and something I find very interesting as well as, and is topical to today's day and age is that there are some people who are hypothesizing that things like COVID or other diseases may be leading to an increased prevalence outside of just things like diabetes. But in regards to lifestyle changes, that's one of the first things that we discuss with patients, because once we've made a diagnosis of gastroparesis, it's not simply about changing or adding medications or proceeding to the operating room.

Treating gastroparesis takes a lot of work. It takes patients changing the way that they eat, whether or not that be different types of meals or amount of meals throughout the day. But also changing the way that they live. If patients have diabetes, we make sure that their diabetes is under good control. If they're on medications like narcotic pain medications, we have to make sure that they're off of those things. In addition to that, we want to make sure that all of their medications are optimized. And then, once we've made different lifestyle changes; we can proceed to trying medications or other interventions, but it's definitely a multimodal approach. And there's not just one answer, which is what I think makes the disease both interesting to the physician, but also difficult for the patient to understand.

Host: And generally, I'm sure it's different for every patient like they say that how long should improvement take?

Dr. Sujka: Well, that again is a difficult thing to answer. For everybody it's different. It changes depending on what type of disease each patient has. When we were talking about things like idiopathic, where we don't really know why patients have gastroparesis, sometimes they don't ever get better with intervention because of the fact that we don't really have a good handle on why they have that disease. People who have more consistent etiologies like diabetes or post-surgical gastroparesis, tend to have better outcomes, but honestly, no, most patients do not get full symptom resolution. And one of the things we are working towards with them is improving their symptoms so they can have a better quality of life.

So, it's not a straightforward answer on how long patients should be expecting to get to feeling perfect because they may not ever. It's more important to discuss how can we improve patients' lives and what do we need to do to get to that point? And as I said earlier, it's different for every patient.

Host: this never happened with children or is it mostly in adults?

Dr. Sujka: To my understanding, and I would love Dr. Thelin's input on this, I believe it's mostly a disease of the adult population.

Dr. Thelin: I agree with Dr. Sujka. It is a diagnosis that's mainly in adult populations. It tends to have a prevalence in Caucasian and women patients. And there are other etiologies that have sort of the same symptomology in children, but they are most likely related to an alternative diagnosis. And I would like to add that I agree with Dr. Sujka, the initial management is dietary and lifestyle modifications, and that it is a multimodal group affair, I think, involving your dietician and your nutritionist who are very well-versed in gastroparetic diets.

This is a common prevalent syndrome and maybe the combination, right. We've talked about how gastroparesis can have an etiology secondary to their medical condition of diabetes. And so then it becomes an uber specialized dietary modification where it's diabetic plus gastroparetic. And so involving them early on is very important. I think that that being said, for the diabetics, glycemic control is important, involving endocrinology is also a very useful tool in that setting or primary care physicians that are well-versed in managing diabetic care and removing the medicines that can cause issues and sort of limit contractility of the stomach and emptying time is important. Just like we talked about with Dr. Sujka, the narcotics and narcotics are not the only medicines that can cause limited antral or gastric contractility. So, reviewing the medicine list is also very important. And then finally, I completely agree that we have to set a goal of care and helping the patient understand that perhaps the end goal is not complete resolution of symptoms, but improvement.

And we actually have certain guidelines that we can use. So, symptom index, so we have three different. One is called the gastroparesis Cardinal symptom index. One is called the patient's assessment of upper gastrointestinal disorders quality of life, and then daily diaries that really help the patient understand that this is going to be a daily improvement. This is going to be a long haul improvement and perhaps it's never to get that complete resolution, but it's to make the symptoms lesser.

Host: Wow. That's amazing. I had no idea about any of this. So, you taught me a lot for sure, both of you. Dr. Thelin and Sujka. Thank you so much. Is there anything else you'd like to add that people listening should know about gastroparesis?

Dr. Sujka: What I'd like to add about gastroparesis is that we didn't get too much into this during our conversation today, but I think that medication interventions are truly very important and I'd like Dr. Thelin to speak to what she specifically feels about progressing with those patients. But from the surgical side of things, I would like to just express that, you know, there are always new things coming out in regards to gastroparesis and treatment, but that our two main treatment algorithms include doing either an endoscopic or robotic pyloroplasty, which includes cutting the pyloric muscle, so the stomach empties and then the other is to perform what's called a gastric neuro stimulator. That's where we place wires in the stomach to improve symptoms as well as sometimes emptying for patients' stomachs. And that's important from the surgical standpoint as these are some of the most important pieces in our armamentarium, but also are not perfect, which I think is disappointing, but means that we have room for improvement in the future.

Dr. Thelin: Yes. And I would like to add that in management of gastroparesis, if dietary modifications and avoidance of those large meals and those fatty, acidic, spicy, fibrous meals and avoidance of alcohol and tobacco and other drugs that can decrease the antral contractility do not work efficiently to improve your quality of life; now, then we start looking at medical therapy like antiemetics and we combine those with neuro gut modulators, for example, SNRIs and TCAs that can decrease the information that you're getting from afferent pain neurons to the brain. And we also look at using prokinetics, which are a small, but robust handful of medications.

I will say, and I think Dr. Sujka probably agrees with me that these are what I like to nickname, dirty drugs. They're drugs that I use with one hand tied behind my back. And they are not first-line therapy for me. And the reason is that they do come with a significant side effect profile. So, there is a handful of dopamine 2 antagonists, serotonin agonist, serotonin 3, so 5-HT3 antagonists that all improve gastric emptying, but they can cause issues like tardive dyskinesia or dystonia or Parkinsonism related side effects in adult patients. They can lead to cardiac arrhythmias. They can also cause tachyphylaxis. And so while they are very helpful, they should not be first-line therapy for this syndrome, unfortunately.

Host: Okay.

Dr. Thelin: There are newer agents that are coming down the pipeline, just like we talked about how there are newer surgical interventions that we are investigating. And these include medicines that are kind of focused on the gastroparetics that are with an etiology of diabetics. So seems like pentapeptide ghrelin receptor agonist, and neurokinin 1 antagonist. And I'd like to mention that one of these, which is a serotonin agonist is actually on the market currently right now.

And that is prucalopride. It's the new kid on the block. It's a highly selective 5-HT₄ receptor agonist that acts like a prokinetic in the gut. And it's actually FDA approved for chronic constipation, which is another dysmotility syndrome. And these patients have actually been studied. Gastroparetic patients have been studied in use of prucalopride and there have been incredible outcomes as far as this quality of life improvement.

And the reason I mention this, and I, I want to end on a note of hope, just like Dr. Sujka was saying is that while we cannot reverse, and while we cannot alleviate a hundred percent of the symptomology of gastroparesis, because there is a lot that's still unknown for us. These newer agents really are less dirty, as I've said before, right. They have less of a side effect profile. And so they are going to allow us the ability to treat patients with improvement in both their quality of life and also potentially the side effects that they have to feel from these medicines. So, I think we both are really excited about the future. There's a lot unknown, but that means that there is a lot to look forward to and a lot of research, which is also occurring at University of South Florida. And we're really excited to be working together.

Host: Well, that sounds encouraging and you're right, that is a good way to wrap it up. Thank you so much, Dr. Thelin and Dr. Sujka. It's been a pleasure and very educational. We appreciate you shining a light on gastroparesis, which a lot of people may not be familiar with.

Maggie McKay (Host): Thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand, videos and local events offered to you by Tampa general hospital, please visit CME dot T G h.org.

Host: Until next time, I Maggie McKay. Thank you for listening and be well,