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Gastroparesis Flashcards

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1
Q

What is gastroparesis?

A

SYMPTOMS consistent with delayed gastric emptying

WITHOUT mechanical obstruction

AND delay in 4 hr solid phase gastric

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2
Q

Gastroparesis is usually caused by:

A

50% idiopathic!! Mostly women
Neuropathy.
Injury to the ENS is common
Vagal injury is not the cause in all patients

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3
Q

What are the Sx of gastroparesis?

A 
N/V
Early satiety
Epigastric pain
Anorexia and weight loss
GERD
Bloating
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4
Q

What are some causes of gastroparesis?

A 
Diabetes
Surgery
Ischemia
Neurologic
Inflamatory
Meds
Transplant
Cirrhosis
Paraneoplastic
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5
Q

Describe the five components of the pathophys of gastroparesis

A
  1. Fundal hypomotility
  2. Antral hypomotility
  3. Antropyloroduodenal spasm
  4. Gastric pacemaker dysrhythmias
  5. excessive inhibitory feedback w/ NO or VIP
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6
Q

What’s on your differential for gastroparesis?

A

Functional dyspepsia
Mechanical obstruction
rumination
Medication

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7
Q

What are the complications of gastroparesis?

A
  1. bezoar
  2. GERD
  3. Cholecystectomy
  4. Mallory-weiss tear
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8
Q

What is the best test for gastroparesis?

A

4 hour solid phase gastric emptying scan

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9
Q

How do we treat gastroparesis?

A
  1. Diet: Small, low fat/fiber meals with liquids
  2. Prokinetics (metoclopramid and erythromycin
  3. Antiemetics
  4. gastric stimulation
  5. Surgery
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10
Q

How does metoclopramide work?

A

Increases ACh release

Inhibits dopamine receptors everywhere

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11
Q

What are the side effects of metoclopramide?

A

Tardive dyskinesia

Also acute dystonic reaction, parkinsonism

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12
Q

How does erythromycin work?

A

Induces Phase III of the MMC

–>more antral contractions

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13
Q

What are some challenges in treating gastroparesis?

A
  1. Symptoms do not correlate with rate of gastric emptying
  2. Treat predominant synptom
  3. Avoid surgery
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14
Q

What are the diagnostic criteria for functional dyspepsia?

A

Rome III: 1+ of the following

  1. Bloating after meals
  2. Early satiety
  3. Epigastric pain (most common)
  4. Epigastric burning

ALSO, no evidence of structural disease and 3 months of Sx PLUS onset 6 mos before diagnosis

Weight loss is also common

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15
Q

What are common causes of functional dyspepsia?

A
  1. Genetics
  2. Post-infectious
  3. inflammatory state
  4. Meds
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16
Q

What studies might be helpful for functional dyspepsia?

A

Upper endoscopy
CBC, LFT< ESR
–If vomiting, consider gastric emptying scan

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17
Q

What is highest on your differential for functional dyspepsia?

A

Gastroparesis

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18
Q

Treating FD is difficult–there’s no one medication that works! What are available options?

A
  1. Dietary/lifestyle changes
  2. H pylori eradication
  3. Antisecretory therapy (lowers acid secretion)
  4. Prokinetics
  5. Tricyclic antidepressants (SNRIs not effective)
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19
Q

What is the most common functional gastrointestinal disorder?

A

The most common functional gastrointestinal disorder–10-12%. Abdominal PAIN + discomfort and a change in bowel function

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20
Q

What are the diagnostic criteria for IBS?

A

Rome III:

  1. Recurrent abdominal pain or discomfort WITH 2+ of the following:
    - Improves with defecation
    - change in stool frequency
    - change in stool form

At least 3 months with Sx and 6 mos after onset. DEFINED by Sx with normal blood work, imaging, and endoscopy

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21
Q

What are the three types of IBS?

A
  1. constipation
  2. diarrhea
  3. alternating
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22
Q

Describe the pathophysiology of IBS

A

A bunch of genetic/environmental/other factors affect serotonin, CRF, and adenosine levels in brain and bowel causing a change in motility, and visceral hypersensitivity

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23
Q

What are the four main symptoms of IBS?

A
  1. Abdominal pain/discomfort
  2. Bloating
  3. Constipation
  4. Diarrhea
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24
Q

What are some red flags when evaluating a pt with suspected IBS that would lead you down another path?

A
  1. weight loss
  2. > 50 yrs
  3. Anemia
  4. High ESR or WBC or TSH
  5. Rectal bleeding
  6. Arthritis/rashes
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25
What is the purpose of doing a colonoscopy in IBS?
Not that useful...except for identifying more patients with microscopic colitis in pts > 45 years
26
How do you treat IBS?
Treat the symptom: 1. Pain=Antidepressants 2. Bloating: Serotonin agonist, or dietary 3. Constipation: Fiber, Mom/PEG 4. Diarrhea: Loperamide, Serotonin agonist All can be treated with serotonin agonists/antagonists.
27
What is the IBS diet?
Low carbs, fructose, gluten, Fermentable Oligo, Di, Mono, polysaccharides and Polyols(FODMAP) - No fruits - No wheat/rye - No artificial sweeteners w/ sorbital - No raffinose (lentils/cabbage, brussels, asparagus)
28
What CAN you eat on IBS?
lean protein - gluten free - rice/corn/oat - Select fruit/veg - snow peas, bok choy, mandarin oranges
29
What other therapies (microbiome related) that can be used in IBS?
Probiotics (bifidobacteria) | Antibiotics (Rifaximin
30
What is the only drug that has been approved to treat IBS-D?
Alosetron. It's a serotonin (5hT-3) receptor antagonist
31
What anti-osmotic agent is useful for IBS?
PEG
32
What drug is approved for IBS-C?
Lubiprostone, a type 2 chloride channel activator | -Increases choloride in lumen, Na follows to balance charge, and H2O follows
33
What are the enteric nervous system neurons derived from? What does it receive input from?
Neural crest cells | --Input from CNS and ANS, but is SELF functioning!
34
What are the two components of the enteric plexus?
submucosal and myenteric plexi
35
Which two layers does the submucosal plexus lie between? Which sections of the GI tract does it populate?
The inner circular muscle layer and mucosa. Found only in the small and large bowel
36
Between which two layers does the myenteric plexus lie btw? Which sections of the tract does it populate?
Between muscular inner circular and outer longitudinal layers. Found along the whole GI tract.
37
What does the submucosal plexus innervate?
1. Secretory cells 2. Endocrine cells 3. Blood vessels
38
What does the myenteric plexus innervate?
1. SECRETOmotor innervation
39
What are the major excitatory neurotransmitters in the GI tract?
Ach, substance P, and tachykinins
40
What are the major inhibitory neurotransmitters in the GI tract?
Nitric oxide | VIP
41
What is the role of serotonin in the GI tract?
Found in interneurons for motor, sensory, and secretory fxn
42
What are IPANs?
Intrinsic primary afferent neurons. They are the primary neurons carrying sensory signals and are embedded in the mucosa. In contrast, extrinsic afferent neurons have cell bodies in DRGs
43
What do interneurons do?
Helps with crosstalk btw sensory and motor neurons (myenteric plexus) to cause peristalsis.
44
The main fxn of the vagus nerve in the GI is:
SENSORY afferent!
45
Describe the physiology of peristalsis
IPAN-->Myenteric plexus-->interneuron in myenteric plexus-->efferent motor neuron in myenteric plexus
46
What are the pacemaker cells of the gut?
Interstitial cells of cajal. "Pace" of the stomach is slower than the small intestine
47
What is the main fxn of the fundus?
Accommodating the food. High tone and low peristalsis
48
What is the main fxn of the antrum?
Grinding food. Low tone and high peristaltic activity
49
What nerve helps expand the fundus and initiate the grinding action of the antrum?
The vagus
50
What will a normal/abnormal EGG look like (Electrogastrography)?
Normal: coordinated movement Abnormal: Not coordinated
51
What is gastric motility in the fed state?
Persistent, irregular contractile activity
52
What is gastric motility in the fasting state?
MMC: Phase I: quiescence Phase II: irregular phasic activity (antrum) Phase III: short period of intense contraction (smal bowel)
53
What is the pathogenesis of nausea/vomiting?
Vagal/sympathetic afferents from all over-->stimulate vomiting center in medulla OR: Chemoreceptor in area postrema of 4th ventrical outside BBB-->vomiting center OR: afferents from CNS-->stimulate vomiting center
54
What is the most common acute cause of nausea and vomiting?
INFECTIONs
55
What are common causes of chronic N/V?
gastroparesis Intestinal pseudo-obstruction Psychogenic vomiting
56
What is the one symptom REQUIRED for gastroparesis?
Vomiting
57
What is the "braking mechanism" for the small bowel?
ileocecal valve
58
What stimulates the GI externally?
Parasympathetic innervation
59
What inhibits the GI internally?
Sympathetics
60
Which syndromes cause disorders in small bowel dysmotility?
1. Scleroderma 2. Hollow Visceral myopathy 3. Intestinal pseudo-obstruction 4. Irritable bowel syndrome
61
What happens in scleroderma?
Aperistalsis from loss of GI smooth muscle - ->Esophagus most common, then small intestine/anorectal. - ->gastric motility is preserved, with its 3 layers of muscle
62
What is the fxn of the colon?
Absorption Formation of residue (poo poo) storage Transport
63
What are the three types of normal colonic motor patterns?
1. Segmenting contractions (for mixing) | 2. Propagating contractions (Low amplitude for short distance, high amplitude for long distances post meal)
64
What is Hirschsprung's disease?
Failure of neural crest cells to move to the colon. Aganglionosis. Sx: failure to thrive, distention, bloating, constipation. Pt won't poop, with colonic dilation above affected segment
65
How do you diagnose hirschsprung's?
anorectal manometry or biopsy
66
How do you tx hirschsprung's?
surgery
67
What is anorectal manometry?
Put a balloon in rectum. Normally will cause RAIR (recto-anal inhibitory reflex) causing relaxation of the internal sphincter. The external sphincter is consciously controlled
68
What is colonic inertia?
Happens in young women, with infrequent stools (every 1-4 weeks) Caused by loss if ICC cells

GI (27 decks)

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