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Batty K, Pugh P, Schwartzbauer A, Carvalho T, Demidowich AP. Diabetes-Related Gastroparesis in the Acute Care Setting: A Case Report. AACN Adv Crit Care 2023; 34:47-52. [PMID: 36877648 DOI: 10.4037/aacnacc2023730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Diabetes-related gastroparesis is a challenging complication of diabetes that often results in flares of intractable vomiting and recurrent hospitalizations. Currently, there is no standard of care or guidelines for the management of diabetes-related gastroparesis in the acute care setting, leading to inconsistent and suboptimal care for these patients. Consequently, patients with diabetes-related gastroparesis may have prolonged inpatient lengths of stay and frequent readmissions affecting their overall health and well-being. Successful management of diabetes-related gastroparesis requires a coordinated multimodal approach to address the different components of an acute flare, including nausea and vomiting, pain, constipation, nutrition, and dysglycemia. This case report demonstrates how the development and implementation of an acute care diabetes-related gastroparesis treatment protocol demonstrates efficacy and promise for better quality of care for this population.
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Affiliation(s)
- Kristine Batty
- Kristine Batty is Endocrine Nurse Practitioner, Johns Hopkins Community Physicians, Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, 5755 Cedar Lane, Columbia, MD 21044 ; and Joint Faculty Appointment, Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Patricia Pugh
- Patricia Pugh is Chair and Medical Director, Department of Emergency Medicine, Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, Maryland
| | - Alyson Schwartzbauer
- Alyson Schwartzbauer is Nurse Practitioner, Department of Anesthesia and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Tricia Carvalho
- Tricia Carvalho is Nurse Practitioner, Gastro Health of Maryland, Columbia, Maryland
| | - Andrew P Demidowich
- Andrew P. Demidowich is Assistant Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and Chief of Inpatient Endocrinology, Johns Hopkins Community Physicians, Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, Maryland
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2
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Mathew AG, Kaye AJ, Patel SJ, Meyers SR, Saiganesh P, Wang W. Outcomes of Gastroparesis in Hospitalized Patients With Generalized Anxiety Disorder. Cureus 2023; 15:e35832. [PMID: 37033595 PMCID: PMC10075333 DOI: 10.7759/cureus.35832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2023] [Indexed: 03/08/2023] Open
Abstract
Background Gastroparesis is a common gastrointestinal pathology that has been increasing in prevalence and represents a significant cost to the United States healthcare system. Gastroparesis is associated with psychological dysfunction, including generalized anxiety disorder (GAD). GAD is known to be a prevalent and chronic manifestation of anxiety, which has been increasing in prevalence since the year 2020. Despite the association between gastroparesis and GAD, there has been limited research on the possible impact GAD may have on the morbidity and mortality of patients hospitalized for gastroparesis, which is further evaluated in this study. Methods Using the Nationwide Inpatient Sample from the year 2014, a retrospective study was conducted to assess the outcomes of hospitalized gastroparesis patients with and without a history of GAD. In this study, the analyzed outcomes included acute kidney injury (AKI), acute respiratory failure, sepsis, acute deep vein thrombosis, myocardial infarction, intestinal obstruction, and inpatient mortality. To assess whether GAD is an independent risk factor for the outcomes, a multivariate logistic regression analysis was used. Results There were 22,150 patients with gastroparesis assessed in this study; GAD was found to be a comorbid diagnosis in 4,196 of those patients. In the GAD cohort, there was an elevated risk for AKI (adjusted odds ratio 1.24, p < 0.001). The adjusted odds ratios for acute respiratory failure, sepsis, acute deep vein thrombosis, myocardial infarction, intestinal obstruction, and inpatient mortality did not meet the threshold for statistical significance. Conclusion In hospitalized gastroparesis patients, GAD is a risk factor for AKI. This finding may be attributed to prerenal azotemia due to an increased risk of nausea and vomiting associated with GAD, as well as the medications used to treat GAD such as escitalopram and duloxetine. In addition, the dual inflammatory states caused by the co-existence of both GAD and gastroparesis may also have a role in increasing the risk for AKI. The results of this study may become increasingly relevant given the increasing prevalence of GAD. .
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Shahsavari D, Thomas R, Ehrlich AC, Feinstein LH, Malik Z, Parkman HP. Demographics of Gastroparesis Hospitalizations Through the Age Spectrum Using National Inpatient Databases: Children Compared With Adults. J Clin Gastroenterol 2022; 56:679-687. [PMID: 34653068 DOI: 10.1097/mcg.0000000000001617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/24/2021] [Indexed: 12/10/2022]
Abstract
GOAL The goal of this study was to characterize the etiology and demographics of hospitalized patients with gastroparesis (Gp) across different age groups. BACKGROUND Gp is a chronic condition associated with increasing hospitalizations and costs. The gender and etiology distributions of Gp throughout the age spectrum are unknown. MATERIALS AND METHODS Nationwide Inpatient Sample (NIS) and Kid's Inpatient Database (KID) were used to identify patients using International Classification of Diseases (ICD)-10 codes for Gp as a primary diagnosis or as secondary diagnosis with the first diagnosis a GI-related symptom. RESULTS There were a total of 15,790 admissions (75.6% female, age: 46.2±18.0 y). After age 6, female admissions percentage increased: ages 2 to 5: 45.0%, ages 6 to 12: 62.8%, ages 13 to 20: 76.7% ( P <0.001), with a distinct increase at age 12. Diabetic gastroparesis (DG) was seen in 3995 (25.3%) of all Gp admissions but in only 1.1% of children under the age of 20. Overall, 68% of DG admissions were female, but a higher percentage of DG was seen among male admissions for Gp compared with female admissions for Gp between ages 21 and 64 (38.3% vs. 23%, P <0.001). The most common races were white (63.2%), African American (20.6%), and Hispanic (8.7%). DG was more often present in Native American (61.9%), Hispanic (39.1%), and African American (38.2%) admissions than in white patients (17.8%; P <0.05). CONCLUSIONS This study using large inpatient databases shows that the gender, race, and etiology of Gp admissions is age-dependent. The female predominance of Gp admissions is more prominent from the second decade of life. DG, although uncommon in children, is seen more often in nonwhite admissions.
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Affiliation(s)
| | | | | | - Laurence H Feinstein
- Department of Pediatrics, Saint Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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Eseonu D, Su T, Lee K, Chumpitazi BP, Shulman RJ, Hernaez R. Dietary Interventions for Gastroparesis: A Systematic Review. Adv Nutr 2022; 13:1715-1724. [PMID: 35425953 PMCID: PMC9526854 DOI: 10.1093/advances/nmac037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 02/09/2022] [Accepted: 04/04/2022] [Indexed: 01/28/2023] Open
Abstract
Gastroparesis (Gp) is a delay in gastric emptying in the absence of a mechanical obstruction and has the capacity to cause symptoms that significantly impact a patient's quality of life. Dietary interventions are the first-line treatment in Gp, but the efficacy of different diets is unclear. This systematic review seeks to determine the effectiveness of dietary interventions on clinical outcomes in Gp. A literature search of MEDLINE Ovid from 1 March 2008 to 1 October 2021 was conducted to identify randomized controlled trials, cohort studies, and cross-sectional studies that reported dietary interventions in Gp. From the initial search, 2789 studies resulted. These were assessed by 2 independent reviewers and selected based on the primary outcomes of interest: changes in symptom-specific patient-reported outcomes and changes in gastric emptying time. A third reviewer resolved any discrepancies. Six adult studies (185 subjects) met the inclusion criteria, whereas no pediatric study did. Five of the included studies were randomized controlled trials and one was an observational study. The systematic review suggested low-fat diets, small-particle diets, diets with isoflavones, and foods considered bland, starchy, sweet, and salty did not exacerbate Gp symptoms. Small-particle diets and diets with isoflavones were found to improve gastric emptying time in patients. Additionally, small-particle diets were shown to reduce anxiety in comparison to large-particle diets. Of the randomized controlled trials, 80% were low risk of bias and 20% were fair risk of bias. The observational study was considered fair quality. The data presented in this review suggest specific dietary interventions could potentially improve Gp symptoms and gastric emptying in adult patients, particularly low-fat and small-particle diets. For pediatric Gp, data are lacking. The limited data available highlights a critical gap in the literature.
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Affiliation(s)
| | - Tanya Su
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Keya Lee
- Texas Medical Center Library, Houston, TX, USA
| | - Bruno P Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,USDA/ARS Children's Nutrition Research Center, Houston, TX, USA
| | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,USDA/ARS Children's Nutrition Research Center, Houston, TX, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E De Bakey Veterans Affairs Medical Center, Houston, TX, USA
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McCarty TR, Chouairi F, Hathorn KE, Chan WW, Thompson CC. Trends and Socioeconomic Health Outcomes of Cannabis Use Among Patients With Gastroparesis: A United States Nationwide Inpatient Sample Analysis. J Clin Gastroenterol 2022; 56:324-330. [PMID: 33780213 PMCID: PMC8435035 DOI: 10.1097/mcg.0000000000001526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although cannabis may worsen nausea and vomiting for patients with gastroparesis, it may also be an effective treatment for gastroparesis-related abdominal pain. Given conflicting data and a lack of current epidemiological evidence, we aimed to investigate the association of cannabis use on relevant clinical outcomes among hospitalized patients with gastroparesis. MATERIALS AND METHODS Patients with a diagnosis of gastroparesis were reviewed from the National Inpatient Sample (NIS) database between 2008 and 2014. Gastroparesis was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes with patients classified based on a diagnosis of cannabis use disorder. Demographics, comorbidities, socioeconomic status, and outcomes were compared between cohorts using χ2 and analysis of variance. Logistic regression was then performed and annual trends also evaluated. RESULTS A total of 1,473,363 patients with gastroparesis were analyzed [n=33,085 (2.25%) of patients with concomitant cannabis use disorder]. Patients with gastroparesis and cannabis use disorder were more likely to be younger and male gender compared with nonusers (36.7±18.8 vs. 51.9±16.8; P<0.001 and 52.9% vs. 33.5%; P<0.001, respectively). Race/ethnicity was different between groups (P<0.001). Cannabis users had a lower median household income and were more likely to have Medicaid payor status (all P<0.001). Controlling for confounders, length of stay, and mortality were significantly decreased for patients with gastroparesis and cannabis use (all P<0.001). CONCLUSION While patients with gastroparesis and cannabis use disorder were younger, with a lower socioeconomic status, and disproportionately affected by psychiatric diagnoses, these patients had better hospitalization outcomes, including decreased length of stay and improved in-hospital mortality.
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Affiliation(s)
- Thomas R. McCarty
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School. Boston, MA
| | | | - Kelly E. Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School. Boston, MA
| | - Walter W. Chan
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School. Boston, MA
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School. Boston, MA
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Saleem S, Inayat F, Aziz M, Then EO, Zafar Y, Gaduputi V. In‐hospital mortality in gastroparesis population and its predictors: A
United States
‐based population study. JGH Open 2021; 5:350-355. [PMID: 33732881 PMCID: PMC7936611 DOI: 10.1002/jgh3.12500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 01/17/2023]
Affiliation(s)
- Saad Saleem
- Department of Internal Medicine Sunrise Hospital and Medical Center Las Vegas Nevada USA
| | - Faisal Inayat
- Department of Internal Medicine Allama Iqbal Medical College Lahore Pakistan
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology University of Toledo Medical Center Toledo Ohio USA
| | - Eric O Then
- Department of Internal Medicine St. Barnabas Hospital, Health System Bronx New York USA
| | - Yousaf Zafar
- Department of Internal Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Vinaya Gaduputi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine St. Barnabas Hospital, Health System Bronx New York USA
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Factors Associated With Hospital Admissions and Readmissions in Patients With Gastroparesis Using the Nationwide Readmission Database. J Clin Gastroenterol 2020; 54:801-805. [PMID: 31851105 DOI: 10.1097/mcg.0000000000001295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Gastroparesis can be associated with severe symptoms. Health care utilization for gastroparesis has increased in part due to an increase in hospital admissions. GOALS To characterize patients admitted for gastroparesis-related symptoms and determine risk factors associated with 30-day readmissions. STUDY The Nationwide Readmission Database (NRD) for the year 2014 was used to identify patients admitted to hospitals using the International Classification of Diseases (ICD)-9 code for gastroparesis as primary diagnosis or as the secondary diagnosis with first diagnosis code of a gastroparesisrelated symptom. Logistic regression was used to determine risk factors associated with 30-day readmission. RESULTS There were 5268 gastroparesis patients admitted with the average length of stay (LOS) of 5.4±6.6 days. Age averaged 48.9±18.1 years, 73.8% were female individuals, and 31% had diabetes. Inpatient mortality was 0.4%. The overall 30-day readmission rate was 6.2%. Longer LOS [odds ratio (OR)=1.4; 95% confidence interval (CI), 1.0-1.9], younger age, drug abuse (OR=1.6; 95% CI, 1.2-2.2), and marijuana use (OR=1.7; 95% CI, 1.0-2.7) were associated with increased risk of 30-day readmission. Female gender (P=0.083), opioid use (P=0.057), and admission to larger hospital (P=0.070) showed a trend toward higher readmission rates. Older patients, and patients with hypertension and diabetes showed lower rates of readmission. CONCLUSIONS Use of the Nationwide Readmission Database (NRD) allows better understanding of gastroparesis admissions and readmissions. Average hospital stay was 5.4 days with 0.4% mortality rate. Overall 30-day readmission rate was 6.2%. Higher LOS, drug abuse, and marijuana use increased the 30-day readmission rate. Diabetes, hypertension, and older age were associated with lower readmissions.
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Kovacic K, Elfar W, Rosen JM, Yacob D, Raynor J, Mostamand S, Punati J, Fortunato JE, Saps M. Update on pediatric gastroparesis: A review of the published literature and recommendations for future research. Neurogastroenterol Motil 2020; 32:e13780. [PMID: 31854057 DOI: 10.1111/nmo.13780] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/11/2019] [Accepted: 11/29/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to scarcity of scientific literature on pediatric gastroparesis, there is a need to summarize current evidence and identify areas requiring further research. The aim of this study was to provide an evidence-based review of the available literature on the prevalence, pathogenesis, clinical presentation, diagnosis, treatment, and outcomes of pediatric gastroparesis. METHODS A search of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines with the following databases: PubMed, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and Web of Science. Two independent reviewers screened abstracts for eligibility. KEY RESULTS Our search yielded 1085 original publications, 135 of which met inclusion criteria. Most articles were of retrospective study design. Only 12 randomized controlled trials were identified, all of which were in infants. The prevalence of pediatric gastroparesis is unknown. Gastroparesis may be suspected based on clinical symptoms although these are often non-specific. The 4-hour nuclear scintigraphy scan remains gold standard for diagnosis despite lack of pediatric normative comparison data. Therapeutic approaches include dietary modifications, prokinetic drugs, and postpyloric enteral tube feeds. For refractory cases, intrapyloric botulinum toxin and surgical interventions such as gastric electrical stimulation may be warranted. Most interventions still lack rigorous supportive data. CONCLUSIONS Diagnosis and treatment of pediatric gastroparesis are challenging due to paucity of published evidence. Larger and more rigorous clinical trials are necessary to improve outcomes.
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Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Walaa Elfar
- Division of Gastroenterology and Nutrition, Department of Pediatrics, The Pennsylvania State Melton S. Hershey Medical Center, Hershey, PA, USA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Mercy Hospital, Kansas City, MO, USA
| | - Desale Yacob
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Jennifer Raynor
- Edward G. Miner Library, University of Rochester Medical Center, Rochester, NY, USA
| | - Shikib Mostamand
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jaya Punati
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John E Fortunato
- Neurointestinal and Motility Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Holtz Children's Hospital, Miller School of Medicine, University of Miami, Miami, FL, USA
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Hirsch W, Nee J, Ballou S, Petersen T, Friedlander D, Lee HN, Cheng V, Lembo A. Emergency Department Burden of Gastroparesis in the United States, 2006 to 2013. J Clin Gastroenterol 2019; 53:109-113. [PMID: 29256990 PMCID: PMC6005709 DOI: 10.1097/mcg.0000000000000972] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis, a chronic gastrointestinal disorder defined by delayed stomach emptying in the absence of obstruction, is often associated with frequent and costly visits to the emergency department (ED). The aim of this study was to analyze trends in gastroparesis-related ED visits from 2006 to 2013. MATERIALS AND METHODS Patients with a primary diagnosis of gastroparesis were identified from the Nationwide Emergency Department Sample (NEDS), the largest publicly available ED all-payer representative database in the United States. ED visits, admission rates, duration of hospitalizations, and charges were compiled. Patients with a secondary diagnosis of diabetes mellitus were analyzed as a subgroup. RESULTS The number of ED visits for gastroparesis as a primary diagnosis in the United States increased from 15,459 in 2006 to 36,820 in 2013, an increase from 12.9 to 27.3 per 100,000 ED visits. The total charges associated with these ED visits and subsequent admissions increased from $286 million to $592 million. In contrast, admission rates through the ED decreased by 22%, procedure rates decreased by 6.2%, and the mean length of stay was shortened by 0.6 days. ED visits for patients with diabetic gastroparesis increased from 5696 to 14,114, an increase from 4.7 to 10.5 per 100,000 ED visits, with an increase in total associated charges for ED visits and subsequent admissions from $84 million to $182 million. CONCLUSIONS The number of ED visits and associated charges for a primary diagnosis of gastroparesis with or without a secondary diagnosis of diabetes mellitus rose significantly from 2006 to 2013.
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Affiliation(s)
- William Hirsch
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Nee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Ballou
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Travis Petersen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Friedlander
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ha-Neul Lee
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian Cheng
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Lembo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Camilleri M, Chedid V, Ford AC, Haruma K, Horowitz M, Jones KL, Low PA, Park SY, Parkman HP, Stanghellini V. Gastroparesis. Nat Rev Dis Primers 2018; 4:41. [PMID: 30385743 DOI: 10.1038/s41572-018-0038-z] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroparesis is a disorder characterized by delayed gastric emptying of solid food in the absence of a mechanical obstruction of the stomach, resulting in the cardinal symptoms of early satiety, postprandial fullness, nausea, vomiting, belching and bloating. Gastroparesis is now recognized as part of a broader spectrum of gastric neuromuscular dysfunction that includes impaired gastric accommodation. The overlap between upper gastrointestinal symptoms makes the distinction between gastroparesis and other disorders, such as functional dyspepsia, challenging. Thus, a confirmed diagnosis of gastroparesis requires measurement of delayed gastric emptying via an appropriate test, such as gastric scintigraphy or breath testing. Gastroparesis can have idiopathic, diabetic, iatrogenic, post-surgical or post-viral aetiologies. The management of gastroparesis involves: correcting fluid, electrolyte and nutritional deficiencies; identifying and treating the cause of delayed gastric emptying (for example, diabetes mellitus); and suppressing or eliminating symptoms with pharmacological agents as first-line therapies. Several novel pharmacologic agents and interventions are currently in the pipeline and show promise to help tailor individualized therapy for patients with gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Victor Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ken Haruma
- Department of Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama, Japan
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Seon-Young Park
- Division of Gastroenterology, Chonnam National University School of Medicine, Gwangju, Republic of Korea
| | - Henry P Parkman
- GI Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Vincenzo Stanghellini
- Department of Digestive Diseases, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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11
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Qayed E, Muftah M. Frequency of hospital readmission and care fragmentation in gastroparesis: A nationwide analysis. World J Gastrointest Endosc 2018; 10:200-209. [PMID: 30283603 PMCID: PMC6162246 DOI: 10.4253/wjge.v10.i9.200] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/12/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate rates and predictors of hospital readmission and care fragmentation in patients hospitalized with gastroparesis.
METHODS We identified all adult hospitalizations with a primary diagnosis of gastroparesis in the 2010-2014 National Readmissions Database, which captures statewide readmissions. We excluded patients who died during the hospitalization, and calculated 30 and 90-d unplanned readmission and care fragmentation rates. Readmission to a non-index hospital (i.e., different from the hospital of the index admission) was considered as care fragmentation. A multivariate Cox regression model was used to analyze predictors of 30-d readmissions. Logistic regression was used to determine hospital and patient factors independently associated with 30-d care fragmentation. Patients readmitted within 30 d were followed for 60 d post discharge from the first readmission. Mortality during the first readmission, hospitalization cost, length of stay, and rates of 60-d readmission were compared between those with and without care fragmentation.
RESULTS There were 30064 admissions with a primary diagnosis of gastroparesis. The rates of 30 and 90-d readmissions were 26.8% and 45.6%, respectively. Younger age, male patient, diabetes, parenteral nutrition, ≥ 4 Elixhauser comorbidities, longer hospital stay (> 5 d), large and metropolitan hospital, and Medicaid insurance were associated with increased hazards of 30-d readmissions. Gastric surgery, routine discharge and private insurance were associated with lower 30-d readmissions. The rates of 30 and 90-d care fragmentation were 28.1% and 33.8%, respectively. Younger age, longer hospital stay (> 5 d), self-pay or Medicaid insurance were associated with increased risk of 30-d care fragmentation. Diabetes, enteral tube placement, parenteral nutrition, large metropolitan hospital, and routine discharge were associated with decreased risk of 30-d fragmentation. Patients who were readmitted to a non-index hospital had longer length of stay (6.5 vs 5.8 d, P = 0.03), and higher mean hospitalization cost ($15645 vs $12311, P < 0.0001), compared to those readmitted to the index hospital. There were no differences in mortality (1.0% vs 1.3%, P = 0.84), and 60-d readmission rate (55.3% vs 54.6%, P = 0.99) between the two groups.
CONCLUSION Several factors are associated with the high 30-d readmission and care fragmentation in gastroparesis. Knowledge of these predictors can play a role in implementing effective preventive interventions to high-risk patients.
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Affiliation(s)
- Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30303, United States
- Department of Gastroenterology, Grady Memorial Hospital, Atlanta, GA 30303, United States
| | - Mayssan Muftah
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, United States
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12
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Jehangir A, Parkman HP. Chronic opioids in gastroparesis: Relationship with gastrointestinal symptoms, healthcare utilization and employment. World J Gastroenterol 2017; 23:7310-7320. [PMID: 29142478 PMCID: PMC5677192 DOI: 10.3748/wjg.v23.i40.7310] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/08/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the relationship of chronic scheduled opioid use on symptoms, healthcare utilization and employment in gastroparesis (Gp) patients. METHODS Patients referred to our tertiary care academic center from May 2016 to July 2017, with established diagnosis or symptoms suggestive of Gp filled out the Patient Assessment of Upper GI Symptoms, abdominal pain and demographics questionnaires, and underwent gastric emptying and blood tests. They were asked about taking pain medicines and the types, doses, and duration. We used Mann Whitney U test, Analysis of Variance, Student's t test and χ2 tests where appropriate for data analyses. RESULTS Of 223 patients with delayed gastric emptying, 158 (70.9%) patients were not taking opioids (GpNO), 22 (9.9%) were taking opioids only as needed, while 43 (19.3%) were on chronic (> 1 mo) scheduled opioids (GpCO), of which 18 were taking opioids for reasons that included gastroparesis and/or stomach pain. Median morphine equivalent use was 60 mg per day. GpCO reported higher severities of many gastrointestinal symptoms compared to GpNO including nausea (mean ± SE of mean of 4.09 ± 0.12 vs 3.41 ± 0.12, P = 0.011), retching (2.86 ± 0.25 vs 1.98 ± 0.14, P = 0.003), vomiting (2.93 ± 0.24 vs 2.07 ± 0.15, P = 0.011), early satiety (4.17 ± 0.19 vs 3.57 ± 0.12, P = 0.004), post-prandial fullness (4.14 ± 0.18 vs 3.63 ± 0.11, P = 0.022), loss of appetite (3.64 ± 0.21 vs 3.04 ± 0.13, P = 0.039), upper abdominal pain (3.86 ± 0.20 vs 2.93 ± 0.13, P = 0.001), upper abdominal discomfort (3.74 ± 0.19 vs 3.09 ± 0.13, P = 0.031), heartburn during day (2.55 ± 0.27 vs 1.89 ± 0.13, P = 0.032), heartburn on lying down (2.76 ± 0.28 vs 1.94 ± 0.14, P = 0.008), chest discomfort during day (2.42 ± 0.20 vs 1.83 ± 0.12, P = 0.018), chest discomfort at night (2.40 ± 0.23 vs 1.61 ± 0.13, P = 0.003), regurgitation/reflux during day (2.77 ± 0.25 vs 2.18 ± 0.13, P = 0.040) and bitter/acid/sour taste in the mouth (2.79 ± 0.27 vs 2.11 ± 0.14, P = 0.028). GpCO had a longer duration of nausea per day (median of 7 h vs 4 h for GpNO, P = 0.037), and a higher number of vomiting episodes per day (median of 3 vs 2 for GpNO, P = 0.002). Their abdominal pain more frequently woke them up at night (78.1% vs 57.3%, P = 0.031). They had a lower employment rate (33.3% vs 54.2%, P = 0.016) and amongst those who were employed less number of working hours per week (median of 23 vs 40, P = 0.005). They reported higher number of hospitalizations in the last 1 year (mean ± SE of mean of 2.90 ± 0.77 vs 1.26 ± 0.23, P = 0.047). CONCLUSION GpCO had a higher severity of many gastrointestinal symptoms, compared to GpNO. Hospitalization rates were more than 2-fold higher in GpCO than GpNO. GpCO also had lower employment rate and working hours, when compared to GpNO.
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Affiliation(s)
- Asad Jehangir
- Department of Internal Medicine, Reading Health System, Spruce St/6th Ave, West Reading, PA 19611, United States
- Department of Gastroenterology, Temple University Hospital, Philadelphia, PA 19140, United States
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Hospital, Philadelphia, PA 19140, United States
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Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med 2017; 35:1118-1120. [PMID: 28320545 DOI: 10.1016/j.ajem.2017.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP. METHODS Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05. RESULTS A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP. CONCLUSIONS The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.
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Affiliation(s)
- Rene Ramirez
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA.
| | - Philip Stalcup
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA
| | - Brandon Croft
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA
| | - Michael A Darracq
- UCSF-Fresno, Department of Emergency Medicine, Fresno, CA, USA; Community Regional Medical Center, Fresno, CA, USA
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Bielefeldt K. Adverse events of gastric electrical stimulators recorded in the Manufacturer and User Device Experience (MAUDE) Registry. Auton Neurosci 2016; 202:40-44. [PMID: 26850819 DOI: 10.1016/j.autneu.2016.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/18/2016] [Accepted: 01/25/2016] [Indexed: 12/12/2022]
Abstract
The role of gastric electrical stimulation for patients with refractory symptoms of gastroparesis remains controversial. Open label studies suggest benefit while randomized controlled trials did not demonstrate differences between active and sham intervention. Using a voluntary reporting system of the Federal Drug Administration, we examined the type and frequency of adverse events. METHODS We conducted an electronic search of the Manufacturer and User Device Experience (MAUDE) databank using the keyword 'Enterra' for the time between January of 2001 and October of 2015. We abstracted information about the year of stimulator implantation, the year and type of adverse effect, the resulting intervention and outcome if available. RESULTS A total of 1587 entries described adverse effects related the GES. Only 36 of the reports listed perioperative complications. The vast majority described problems that could be classified as patient concerns, local complications, or system failure. The most common problem related lack or loss of efficacy, followed by pain or complications affecting the pocket site. A subset of 801 reports provided information about the time between system implant and registration of concerns, which gradually declined over time. More than one third (35.7%) of the reported adverse events prompted surgical correction. CONCLUSION The number of voluntarily reported adverse events and the high likelihood of repeated surgical interventions clearly demonstrate the potential downside of gastric electrical stimulation. Physicians considering this intervention will need to carefully weigh these risks and include this information when counseling or consenting patients.
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Affiliation(s)
- Klaus Bielefeldt
- University of Pittsburgh Medical Center, Division of Gastroenterology, 200 Lothrop St., Pittsburgh, PA 15213, United States.
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Abstract
INTRODUCTION While delayed emptying is the defining criterion for gastroparesis, prokinetics often only have a limited impact on symptoms and have been associated with potentially serious adverse effects. The goal of this study was to determine how this information and regulatory changes affected gastroparesis management. METHODS The electronic medical records of patients seen between 2003 and 2012 in the outpatient clinic of a large tertiary center were retrieved based on the billing diagnosis of gastroparesis. Demographic, clinical, and survival data were abstracted. RESULTS A total of 709 patients were identified, with diabetes (21.2 %) and prior surgery (9.8 %) being the most common identifiable causes. The majority of patients (56 %) had idiopathic gastroparesis. The cohort was female predominant (79.5 %) with an average age of 45.4 ± 0.6 years. At the index encounter, 61.8 % received prokinetics. About one-third (37.7 %) used antiemetics at least intermittently. Between 2003 and 2012, prokinetic use dropped from 81 to 43 %, while the use of antiemetics increased from 14 to 41 %. Similarly, there was a significant increase in prescribed opioids and antidepressants. During the period of the study, 44 patients (6.2 %) died. Increasing age, a higher comorbidity burden, anxiety, and medication use were associated with higher mortality risks. CONCLUSION This large outpatient cohort suggests that treatment trends move away from prokinetics and focus on symptom-oriented therapy and/or confounding mood disorders.
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From ischochymia to gastroparesis: proposed mechanisms and preferred management of dyspepsia over the centuries. Dig Dis Sci 2014; 59:1088-98. [PMID: 24715546 DOI: 10.1007/s10620-014-3144-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/26/2014] [Indexed: 12/12/2022]
Abstract
Dyspeptic symptoms are common with most patients suffering functional disorders that remain a therapeutic challenge for medical practitioners. Within the last three decades, gastric infection, altered motility, and hypersensitivity have gained and lost traction in explaining the development of functional dyspepsia. Considering these shifts, the aim of this review was to analyze changing understanding of and approaches to dyspepsia over a longer time period. Monographs, textbooks, and articles published during the last three centuries show that our understanding of normal gastric function has improved dramatically. With increased insight came new ideas about disease mechanisms, diagnostic options, and treatments. Despite shifts over time, the importance of functional abnormalities was recognized early on and explained in the context of societal influences and stressors, anxieties, and biological influences, thus resembling the contemporary biopsychosocial model of illness. Symptoms were often attributed to changes in secretion, motility, and sensation or perception with technological innovation often influencing proposed mechanisms and treatments. Many of the principles or even agents applied more than a century ago are still part of today's approach. This includes acid suppression, antiemetics, analgesics, and even non-pharmacologic therapies, such as gastric decompression or electrical stimulation of the stomach. This historical information does not only help us understand how we arrived at our current state of knowledge and standards of care, it also demonstrates that enthusiastic adoption of various competing explanatory models and the resulting treatments often did not survive the test of time. In view of the benign prognosis of dyspepsia, the data may function as a call for caution to avoid the potential harm of overly aggressive approaches or treatments with a high likelihood of adverse effects.
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Ball WR, Sharples AJ. Massive gastric dilation complicating diabetic gastroparesis. BMJ Case Rep 2013; 2013:bcr-2013-009420. [PMID: 23616329 DOI: 10.1136/bcr-2013-009420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A middle-aged man presented at 4:00 with tense distended abdomen, severe pain and numb legs. His medical background included poorly controlled insulin-dependent diabetes. Abdominal x-ray showed a massively distended, featureless viscus on the left side of the abdomen thought to be a sigmoid volvulus. CT scan was delayed due to respiratory compromise from diaphragmatic splinting. Nasogastric and flatus tube decompression were attempted. Eventually CT was obtained and provisionally reported as a sigmoid volvulus. Emergency laparotomy was performed due to the risk of impending perforation. Operative findings were of a hugely distended stomach extending into the left iliac fossa almost completely occupying the abdominal cavity. Gastrotomy was used to decompress the stomach. No mechanical obstruction was identified. Postoperatively he had an episode of massive haematemesis thought to be due to sloughing of gastric mucosa. He was taken back to theatre and died on table.
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Affiliation(s)
- William Robert Ball
- Department of Surgery, University Hospital North Staffordshire, Stoke-on-Trent, UK.
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