Treatment of gastroparesis
Treatment of gastroparesis
At this stage, gastroparesis cannot be cured, so reducing symptoms and maintaining quality of life are the main goals of gastroparesis treatments.
There are several different treatment options that can help to improve gastroparesis symptoms. Together with your healthcare team, you will develop a gastroparesis treatment plan suited to your needs. Your gastroparesis plan might include a combination of the treatment options below.
Diet is often considered in the treatment of gastroparesis. Food choices and eating pattern can have an impact on gastric emptying and symptoms of gastroparesis. Sometimes symptoms of gastroparesis can reduce your appetite and your food intake. If you lose more than 5% of your body weight unintentionally within three months, it can be an indication of malnutrition. Malnutrition is associated with fatigue, reduced quality of life, depression and may even weaken response to medications. If you are malnourished, and/or struggling to eat without it contributing to symptoms it is recommended that you see a dietitian, who will help customise a diet for you.
General dietary recommendations for gastroparesis:
- Take your meds before meals: If you are prescribed a prokinetic agent, make sure you take it approximately half hour before eating so that its optimal effects are when you eat
- Eat when you feel well: Make sure you have the biggest meal at the time of day when you feel the best
- Eat frequent, small meals: Eating around 6 small meals per day is generally better tolerated in gastroparesis than eating less frequent large meals. Eating smaller meals means that you are less likely to overfill the stomach, which can lead to feelings of nausea and bloating. Drinking fluids between meals, rather than with meals, can also help to prevent the stomach from becoming overly full.
- Chew food well: Chewing food well means that the stomach will not need to do as much work to break down the food.
- Remain upright after eating: Staying upright for at least 1 hour after eating will help the stomach empty more quickly and reduce gastroparesis symptoms.
- Limit high fat foods: Fatty foods, such as fried food and creamy sauces, can slows down gastric emptying and can make gastroparesis symptoms worse.
- Limit high fibre foods: Fibre can slow down gastric emptying, so it is helpful to limit wholegrains, raw vegetables and skins of fruits. Well-cooked vegetables are often well tolerated.
- A modified texture diet may be recommended: It may be suggested that you keep to food textures that are easier to digest, such as soft, well-cooked meats and vegetables, stewed fruits, soft white breads and cereals or porridge. If you have severe gastroparesis, it may be suggested that you puree your food or even keep to a liquid diet. If a liquid diet is indicated, it is essential that you see a dietitian, who will ensure that you receive adequate nutrition through use of oral nutrition supplements, such as ‘Ensure’ or ‘Sustagen’.
- Vitamin and mineral supplements: Due to the dietary restrictions people with gastroparesis can face, a supplement might be recommended to help avoid nutritional deficiencies. Your doctor can check your nutrient status and refer you to a dietitian for dietary support.
- Avoid soft drinks: Fizzy drinks can fill up your stomach and make your symptoms worse.
Diets to help related symptoms of gastroparesis:
People with gastroparesis can commonly become constipated, either due to less fibre and food bulk or because the whole gut slows down. Symptoms of constipation include bloating, abdominal distension, lower abdominal pain and difficulty passing stool. Occasionally, this may also result in very loose stools. There are many different treatments for constipation, depending on the cause. These treatments may include laxatives (in food or medications) or other medications and/or therapeutic diets, such as a low FODMAP diet. Therapeutic diets can be quite restrictive, so if you are experiencing any constipation-related symptoms, it is important that you see a dietitian, who can guide a therapeutic diet without compromising your nutrition.
If dietary changes don’t help
Some patients are unable to maintain adequate nutrition and hydration even after following all of the dietary recommendations for gastroparesis. In these cases, patients may need to use a feeding tube that delivers fluids and nutrients directly to the small intestine. A dietitian will help manage this feeding, if required.
Prokinetics and antiemetics are the main types of medication prescribed for gastroparesis symptoms.
A prokinetic can help to speed up gastric emptying by increasing the muscular contractions in the gastrointestinal tract and moving stomach contents through to the small intestine more quickly.
An antiemetic is used to treat nausea and vomiting.
These medications may be prescribed as a pill, liquid, nasal spray, or can also be administered intravenously.
Tricyclic antidepressants may be prescribed for some gastroparesis sufferers. These medications are known to have an effect on gut function and may help with sensory abnormalities experienced by some patients.
Pain management in gastroparesis can be challenging. While pain medications can be helpful for some patients, it often takes time to identify the appropriate combination of medications.
Pain medications pose some considerable challenges in gastroparesis:
- Pain medications can interact with other medications prescribed for gastroparesis and make symptoms worse
- Strong pain medications (e.g. opiates) can slow down the digestive system even further and increase sensitivity of the gastrointestinal system in the long term. Opiate medications are great for a broken leg or postoperative pain, but are not good in chronic gastrointestinal pain.
- Some pain medications (e.g. opiates) can lead to dependence or addiction when taken over the long term and are associated with a risk of death due to inadvertent overdose.
Due to these challenges, a pain management specialist might be required to help identify the best pain management approach for a gastroparesis sufferer. In some cases, psychological intervention may be recommended to help manage the symptoms.
Gastroparesis is associated with increased anxiety and depression, and poor quality of life. These feelings can present for a number of reasons and may arise before or after gastroparesis symptoms.
Some gastroparesis sufferers find it helps to have the support of a psychologist who is familiar with gastroparesis. A psychologist can help individuals develop strategies to cope with gastroparesis symptoms and gastroparesis-related lifestyle changes. Approaches may include relaxation techniques, hypnosis, biofeedback, and cognitive behavioural therapy (CBT).
For gastroparesis sufferers who also have diabetes, getting blood glucose levels under control is one of the most important parts of their treatment.
High blood glucose can make gastroparesis symptoms worse by:
- delaying gastric emptying
- increasing fullness after meals
- interfering with gastroparesis medications
Gastroparesis also makes it more difficult to control blood glucose levels. For example, gastroparesis:
- makes it harder to predict how long it will take for foods to be absorbed
- can interfere with how diabetes medications are absorbed
For those with diabetic gastroparesis, it can be beneficial to consult with a dietitian who can customize a dietary plan to your needs. Avoiding excessive dietary sugars, spreading out carbohydrate intake throughout the day, and being physically active most days is likely to help.
Enteral & parenteral nutritional support
For individuals who are unable to maintain adequate nutrition through oral intake, a feeding tube may be required. There are many types of feeding tubes that could be used, but one of the most common types for gastroparesis sufferers is the jejunostomy tube.
A jejunostomy tube is a feeding tube that is inserted through the abdomen and into the second part of the small intestine—the jejunum. In gastroparesis, using a jejunostomy tube means that the parts of the gastrointestinal system that are not working properly can be bypassed. This way, the patient can receive nutrition, hydration and medication directly to an area of the gastrointestinal system where it can be absorbed.
A gastric drainage tube may also be used to help relieve gastroparesis symptoms by draining stomach contents. This tube is inserted through the abdomen and into the stomach.
In cases where feeding tubes are not appropriate or do not resolve nutritional deficiencies, parenteral support may be considered. Parenteral support involves the administration of nutrients directly into a vein (i.e. intravenously). This treatment is very expensive and is associated with both short- and long-term complications.
Botox (botulinum toxin) can be injected into the pyloric muscles to help the muscles relax. The pyloric muscles are a ring of muscles (sphincter) between the stomach and duodenum. By relaxing the pyloric muscles with Botox, food should be able to pass from the stomach to the duodenum more easily and therefore improve gastric emptying.
The use of Botox as a treatment for gastroparesis has had varying results, and further research is being conducted to better understand who can benefit from this treatment. It is believed that it may be helpful for a subgroup of gastroparesis sufferers who experience spasms of the pyloric sphincter. Currently, it is only recommended when other treatment approaches have been ineffective.
Pyloroplasty (or pyloromyotomy) is a surgical procedure to widen the valve between the stomach and the duodenum. The valve is called the pylorus and is surrounded by the pyloric sphincter (a ring of muscles). Pyloroplasty involves removing some of the pyloric sphincter to widen the pylorus and allow food to pass through more easily.
Pyloroplasty is most likely to be used if gastroparesis is associated with vagus nerve injury. Over the past few years a number of patients have undergone an endoscopic version of pyloroplasty (G-POEM). Whilst there have been some encouraging initial results, the procedure is still undergoing trials and needs to be used on larger numbers of patients before its place in treatment can be worked out.
Gastric electrical stimulation
Gastric electrical stimulation is like a pacemaker for the gastric muscles. The stimulator is inserted beneath the skin of the abdomen and sends pulses to the smooth muscles of the stomach to speed up gastric emptying. The stimulator can be programmed so that the frequency and intensity of the pulses are customized to the individual.
This is an expensive treatment and does not work for all patients, however some patients report lasting improvements in gastroparesis symptoms.
Some people find complementary therapies to be beneficial in managing chronic symptoms, like those experienced in gastroparesis. These therapies are often used alongside conventional medical treatments but are not always as well researched or understood as conventional medicine.
There is some evidence that acupuncture may help alleviate some gastroparesis symptoms (e.g. nausea), while other therapies may help to reduce stress levels and act in a similar way to psychological treatment.
It is important to inform your doctor of all medications you are taking, including those prescribed by complementary therapists. The treatments may interact with other medications you are taking and can cause side effects and abnormal test results.