Is gastric electrical stimulation superior to standard pharmacologic therapy in improving GI symptoms,healthcare resources,and long-term health care benefits?

CONTEXT: Severe upper gastrointestinal (GI) motor disorders, including gastroparesis (GP), can consume significant health care resources. Many patients are refractory to traditional drug therapy. OBJECTIVE: To compare symptoms, healthcare resource utilization and costs in two groups of patients with the symptoms of GP: those treated via gastric electrical stimulation (GES) and those treated with traditional pharmacological agents in an intensive outpatient program (MED). DESIGN: A long-term comparison of patients with devices (n = 9) vs intensive medical therapy (n = 9). SETTING AND PATIENTS: A total of 18 eligible patients with the symptoms of GP reported for 1-year baseline and long-term treatment for 3 years. INTERVENTIONS: Patients with the symptoms of GP were treated by a GES or intensive medical therapy (MED). MAIN OUTCOME MEASURES: GP Symptoms, healthcare resource utilization using investigator-derived independent outcome measure score (IDIOMS) and total hospital (inpatient and outpatient) billing costs. RESULTS: Gastrointestinal symptoms were significantly different from baseline (F = 3.03, P < 0.017) with GP patients treated via GES showing more sustained improvement over 36 months than those treated via MED. Healthcare resource usage, measured via the IDIOMS, significantly improved at 12, 24 and 36 month follow-up for GES patients (F = 10.49, P < 0.001), compared with patients receiving medical therapy, who demonstrated further deterioration. GP patients treated via GES also proved superior to medical therapy at 24 and 36 months with regard to decreased costs (F = 4.85, P < 0.001). Within group comparisons indicated significantly reduced hospital days for both patient groups; however, no statistical differences were noted between groups in terms of hospital days. Three of nine patients in the MED group died primarily from i.v. access related problems; none of the GES patients died. CONCLUSION: We conclude that GES is more effective in improving long-term GI symptoms and costs, and decreasing use of healthcare resources than intensive medical therapy, in this sample of patients with the symptoms of GP followed for 3 years. Certain patients with GP form a high-risk group in terms of costs, quality of life, morbidity and mortality.     

Postinfectious gastroparesis related to autonomic failure: a case report

BACKGROUND AND AIM: Severe dysautonomia may be secondary to viral infections, resulting in impaired autoimmune, cardiovascular, urinary and digestive dysfunction. Herein, we present a case of a 31-year-old white female patient who had severe gastroparesis related to autonomic failure following an episode of acute gastroenteritis. This seems to be the first report providing thorough assessment of the enteric and autonomic nervous system by analysis of full-thickness small intestinal biopsies, cardiovagal testing and autopsy. HOSPITAL COURSE: This patient affected by a severe gastroparesis was treated with antiemetics, prokinetics, analgesics and gastric electrical stimulation to control symptoms. Nutritional support was made using jejunal feeding tube and, in the final stage of disease, with total parenteral nutrition. Autonomic studies revealed minimal heart rate variability and a disordered Valsalva manoeuvre although the enteric nervous system and the smooth muscle layer showed a normal appearance. Hospital courses were complicated by episodes of bacteraemia and fungemia. Serum antiphospholipid antibodies were noted but despite anticoagulation, she developed a pulmonary embolism and shortly thereafter the patient died. Autopsy revealed acute haemorrhagic Candida pneumonia with left main pulmonary artery thrombus. Sympathetic chain analysis revealed decreased myelinated axons with vacuolar degeneration and patchy inflammation consistent with Guillain-Barre syndrome. The evaluation of the enteric nervous system in the stomach and small bowel revealed no evidence of enteric neuropathy or myopathy. CONCLUSION: A Guillain-Barre-like disease with gastroparesis following acute gastroenteritis is supported by physiological and autonomic studies with histological findings.     

An energy algorithm improves symptoms in some patients with gastroparesis and treated with gastric electrical stimulation

Gastric electrical stimulation (GES) is effective to improve symptoms of nausea and vomiting in most patients, but very little is known about the effect of varying stimulation parameters. We analysed stimulation parameters in a pilot study of 22 patients (12 idiopathic, four diabetic and four postsurgical) with drug-refractory gastroparesis who did not respond optimally to initial settings. Patients underwent high-frequency/low energy GES using identical initial stimulation parameters: 5 mA of current, 330 micros pulse width, 14 Hz for 0.1 s on and 5.0 s off. Due to lack on optimal response, 22 patients underwent alteration of an algorithm using stimulation parameters. At follow-up (mean of 4.3 years) a dose-response relationship for charge, power and energy were compared with baseline for the whole group and for each diagnostic subgroup by anova data are reported as mean +/- SE. Based on the mean of individual dose-response curves, differences in data are charge, current per pulse and energy per pulse were noted for the whole group at follow up vs baseline. The subgroup of patients with postsurgical gastroparesis required the most energy using the algorithm. In conclusion, an algorithmic approach to identify optimal stimulation parameters in GES for individual patients is associated with symptom improvement. Also, certain subgroups appear to have different energy parameters. Based on this preliminary data, the use of an algorithm for some patients with GES is feasible and may have potential for clinical application. A randomized-controlled trial of different stimulation parameters for GES seems warranted.     

Treatment of gastroparesis: a multidisciplinary clinical review

This clinical review on the treatment of patients with gastroparesis is a consensus document developed by the American Motility Society Task Force on Gastroparesis. It is a multidisciplinary effort with input from gastroenterologists and other specialists who are involved in the care of patients with gastroparesis. To provide practical guidelines for treatment, this document covers results of published research studies in the literature and areas developed by consensus agreement where clinical research trials remain lacking in the field of gastroparesis.     

Cyclic vomiting syndrome in adults

Abstract  Cyclic vomiting syndrome (CVS) was initially described in children but can occur in all age groups. Cyclic vomiting syndrome is increasingly recognized in adults. However, the lack of awareness of CVS in adults has led to small numbers of diagnosed patients and a paucity of published data on the causes, diagnosis and management of CVS in adults. This article is a state-of-knowledge overview on CVS in adults and is intended to provide a framework for management and further investigations into CVS in adults.