…all I know is that I know nothing. –Socrates
Perhaps Socrates was a gastroenterologist. So much of what we think we know, we are finding out is poorly understood. This applies to gallbladder dyskinesia, sphincter of Oddi dysfunction and now gastroparesis.
A recent study (PJ Pasricha et al. Gastroenterol 2015; 149: 1762-74, commentary 1666-68) and commentary show how little we understand about gastroparesis.
The study was a large prospective surgery of 262 adult patients with gastroparesis (either diabetic or idiopathic).
- 28% had improvement in the gastroparesis cardinal symptom index (GCSI) at 48 weeks. Beyond 48 weeks, there were no significant reductions through week 192.
- Favorable characteristics: male gender, age 50 and older, initial infectious prodrome (18% of cohort), antidepressant usage, and 4-hour gastric retention greater than 20%.
- Unfavorable characteristics: obesity, smoking, use of pain modulators, moderate to severe abdominal pain, severe reflux, and moderate to severe depression.
The commentary suggests that those with the higher GCSI improved, in part, because of a regression toward the mean bias. Other important commentary:
- “More severely delayed gastric emptying was associated with a greater likelihood of improvement”
- “There was no differences in outcome between diabetic or idiopathic gastroparesis.”
- Gastric emptying tests are not reliable: “Pathophysiologic tests are useful in clinical practice if they are reproducible, explain the symptoms, guide therapeutic choices, and determine response to therapy and long-term prognosis. Despite its popularity, the gastric emptying test scores low on most of these criteria.”
- “A metaanalysis found no correlation between the change in gastric emptying rate and the symptom response during prokinetic therapy…A 5-year prospective follow-up study of …functional dyspepsia…found that more than 50% improved…with no relation to the presence of delayed gastric emptying.”
- “Using the term gastroparesis also can lead to premature closure in our efforts to understand the pathophysiology of symptoms…can lead to botulinum injections into the pylorus or placement of gastric stimulators (formerly called gastric pacemakers) for gastroparesis, both of which have been shown to be nonefficacious in controlled trials.”
My take: It is unclear “when to consider gastric emptying testing and how to use it in patient management.” For the pediatric population, gastroparesis is more likely to be associated with a prodromal infection which increases the likelihood of recovery.
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