Novel Diet, Drugs, and Gastric Interventions for Gastroparesis

Abstract

This review of the pathophysiologic basis for gastroparesis and recent advances in the treatment of patients with gastroparesis shows that there are several novel approaches to advance treatment of gastroparesis including diet, novel prokinetics, interventions on the pylorus, and novel forms of gastric electrical stimulation. The field of gastroparesis is likely to advance with further studies, with help from a guidance document from the Food and Drug Administration on gastroparesis, and with recent approval of the stable isotope gastric emptying test to ensure eligibility of participants in multicenter trials. Clinical experience and a formal, randomized, controlled trial provide insights on optimizing dietary interventions in patients with gastroparesis. This review addresses the biologic rationale of these different treatments, based on known physiology and pathophysiology of gastric emptying. The novel medications include the motilin agonist, camicinal; 5-HT4 receptor agonists, such as velusetrag; and the ghrelin agonist, relamorelin. New approaches target pylorospasm by stent placement, endoscopic pyloric myotomy, or laparoscopic pyloroplasty. These approaches offer the opportunity to achieve more permanent reduction of resistance to flow at the pylorus over the intrapyloric injection of botulinum toxin, which typically has to be repeated every few months if it is efficacious. A novel device, deployed in porcine stomach, involved per-endoscopic electrical stimulation. These promising approaches require formal, randomized, controlled trials and deployment in patients. The presence of concomitant antral hypomotility may be a significant factor in the responsiveness to interventions at the pylorus.

Keywords: Diet; Gastric Emptying; Motility; Myotomy; Prokinetics; Pylorus; Stent.

Figure 1

Patterns of gastric emptying of liquids and solids in health and in gastroparesis. Gastric emptying curves for liquids and solids were derived from the published literature. Low fat solid meal is a 2% fat, 255kcal meal; high fat meal is 32% fat, 296kcal meal. Reproduced with permission from ref. . Camilleri M, Shin A. Dig Dis Sci 2013;58:1813–1815.

Figure 2

Antroduodenal motility tracings in the postprandial period with sensors 1cm apart. Note in the upper example the consistent phasic and tonic contractions at the pylorus with intermittent loss of distal antral contractions 1 and 2 cm proximal to the pylorus. In contrast, note the consistent antropyloric coordination in the normal example in the lower tracings.