Bodyweight in patients with idiopathic gastroparesis: roles of symptoms, caloric intake, physical activity, and body metabolism

Meal Eating Characteristics of Patients with Gastroparesis

BACKGROUND

Patients with gastroparesis often consume only small meals due to early satiety.

AIMS

(1) Describe meal eating characteristics of patients with gastroparesis; (2) Relate meal eating characteristics to symptoms, gastric emptying (GE), and body weight.

METHODS

Patients with gastroparesis filled out questionnaires including Patient Assessment of Upper GI Symptoms (PAGI-SYM), and questionnaire about meal habits and body weight. Patients underwent gastric emptying scintigraphy.

RESULTS

Of 192 gastroparesis patients, 93% endorsed early satiety (ES) with severity of 3.7 ± 1.5 (scored from 0-5) and 93% endorsed postprandial fullness (PPF) with severity of 3.9 ± 1.3. Time spent consuming meals averaged 13.6 ± 17.7 min. Main reasons patients stopped eating were fullness (61%), nausea (48%), and abdominal pain (31%). Time spent eating correlated inversely with severity of nausea (r = -0.18, p < 0.05), stomach fullness (r = -0.21, p < 0.01), PPF (r = -0.23, p < 0.01), loss of appetite (r = -0.34, p < 0.01). Postprandial fullness lasted for 316 ± 344 min. Duration of PPF correlated with nausea (r = 0.30, p < 0.01), retching (r = 0.29, p < 0.01), vomiting (r = 0.28, p < 0.01), stomach fullness (r = 0.33, p < 0.01), loss of appetite (r = 0.35, p < 0.01), and constipation (r = 0.27, p < 0.01). Underweight patients had increased inability to finish a normal size meal (p < 0.01), loss of appetite (p < 0.01), and lower abdominal pain/discomfort (p < 0.05). Patients had lost 3.06 ± 10.60 kgs from their baseline weight. Weight loss correlated with nausea (r = 0.26, p < 0.01), ES (r = 0.30, p < 0.01), loss of appetite (r = 0.28, p < 0.01).

CONCLUSIONS

Early satiety and postprandial fullness were common with high severity. The main reasons for meal cessation were early satiety, nausea, and abdominal pain. Body weight and change in body weight were associated with symptoms of gastroparesis.

Development of a Motility Frailty Index in Patients with Gastroparesis

Introduction: Patients with symptoms (Sx) of gastrointestinal (GI) motor disorders have limitations in physical strength and mobility. We hypothesized that physical frailty correlated with severity of GI symptoms, and that a motility frailty index (MFI) could be constructed. Patients: We conducted a prospective pilot study on 40 patients, (38 F, 2 M, mean age 39.9 years) with the following diagnoses: 10 with diabetes mellitus and 30 with non-diabetic/idiopathic disorders. Upper and lower GI Sx were quantified using an FDA-compliant, traditional patient-reported outcomes (PRO) system. Methods: Patients underwent a series of physical performance measures involving standing balance (SB), usual walk speed (UW), and chair sit-and-stands (CS). A GI motility frailty index (MFI) was constructed by fitting several models with a combination of physical performance measures and correlating with PRO. Pearson’s correlation compared the constructed index with the GI Sx PRO to construct a GI MFI. Results: The studied patients collectively showed marked limitations in mobility compared with standard performance values with mean (sd) ratios of SB = 0.87 (0.20), UW = 0.45 (0.13), and CS = 0.38 (0.17). Correlations between physical mobility and GI Sx were noted for upper GI Sx (rho = 0.47, p = 0.002) but not for lower GI Sx. Conclusions: In this pilot study of patients with GI motility disorders, we found increased physical limitations on performance-based testing, which had a statistically significant positive correlation with severity of upper GI motor Sx using a standardized PRO system. A motility frailty index has been constructed that may serve as a basis for better quantifying limitations in patient mobility.

Epidemiology and outcomes of gastroparesis, as documented in general practice records, in the United Kingdom

OBJECTIVE

To generate real-world evidence for the epidemiology of gastroparesis in the UK, we evaluated the prevalence, incidence, patient characteristics and outcomes of gastroparesis in the Clinical Practice Research Datalink (CPRD) database.

DESIGN

This was a retrospective, cross-sectional study. Prevalence and incidence of gastroparesis were evaluated in the CPRD database, with linkage to Hospital Episodes Statistics Admitted Patient Care and Office for National Statistics mortality data. Prevalence and incidence were age and sex standardised to mid-2017 UK population estimates. Descriptive analyses of demographics, aetiologies, pharmacological therapies and mortality were conducted.

RESULTS

Standardised prevalence of gastroparesis, as documented in general practice records, was 13.8 (95% CI 12.6 to 15.1) per 100 000 persons in 2016, and standardised incidence of gastroparesis rose from 1.5 (95% CI 1.1 to 1.8) per 100 000 person-years in 2004 to 1.9 (95% CI 1.4 to 2.3) per 100 000 person-years in 2016. The most common disease aetiologies were idiopathic (39.4%) and diabetic gastroparesis (37.5%), with a similar distribution of type 1 and type 2 diabetes among the 90% who had type of diabetes documented. Patients with diabetic gastroparesis had a significantly higher risk of mortality than those with idiopathic gastroparesis after diagnosis (adjusted HR 1.9, 95% CI 1.2 to 3.0). Of those with gastroparesis, 31.6% were not offered any recognised pharmacological therapy after diagnosis.

CONCLUSION

This is, to our knowledge, the first population-based study providing data on epidemiology and outcomes of gastroparesis in Europe. Further research is required to fully understand the factors influencing outcomes and survival of patients with gastroparesis.

Body weight in patients with idiopathic gastroparesis

BACKGROUND

The classic clinical picture of gastroparesis is a symptomatic patient losing weight. In addition, a number of patients with delayed gastric emptying are obese and/or gaining weight. Our aim was to investigate the factors impacting body weight in patients with idiopathic gastroparesis.

METHODS

In patients with idiopathic gastroparesis, detailed history and weight were acquired at enrollment and after 48 weeks. Questionnaires assessed symptoms, food intake, physical activity, and quality of life. Patients underwent laboratory testing, gastric emptying scintigraphy, and water load testing.

RESULTS

Of 138 patients with idiopathic gastroparesis, 10% were underweight (BMI < 18.5), 39% were normal weight (BMI 18.5-25), 20% were overweight with BMI 25 to 30 kg/m² , and 29% were obese with BMI > 30 kg/m² . Body weight at enrollment was positively associated with oral caloric consumption (P < .001), following a gastroparesis diet (P = .04), nutrition consultation (P = .001), upper abdominal pain (P = .01); and negatively associated with energy expenditure (P = .05), alcohol use (P = .003) and severity of bloating (P < .001). When followed over 48 weeks, 53% patients stayed stable (within 5% of baseline weight), 30% gained, and 17% lost weight. Weight gain over 48 weeks was positively associated with oral caloric consumption (P = .003) and constipation severity (P = .005) at enrollment, and negatively associated with lower abdominal pain severity (P = .007) at enrollment, and associated with improvement in inability to finish meal score (P < .001) at 48 weeks.

CONCLUSIONS

In this series of patients with idiopathic gastroparesis, 10% were underweight whereas 29% were obese. Over 48 weeks, 30% of patients increased their body weight ≥ 5%. Diet, activity, and symptoms are important factors associated with body weight in patients with idiopathic gastroparesis.

Nutritional approaches for gastroparesis

Patients with gastroparesis often have signs and symptoms including nausea, vomiting, epigastric discomfort, and early satiety, thus leading to inadequate food intake and a high risk of malnutrition. There is a considerable scarcity of data about nutritional strategies for gastroparesis, and current practices rely on extrapolated evidence. Some approaches include the modification of food composition, food consistency, and food volume in the context of delayed gastric emptying. If the patient is unable to consume adequate calories through a solid food diet, stepwise nutritional interventions could include the use of liquid meals, oral nutrition supplements, enteral nutrition, and parenteral nutrition. This Review discusses the role, rationale, and current evidence of diverse nutritional interventions in the management of gastroparesis.

Clinical Manifestation and Natural History of Gastroparesis

Although gastroparesis was described more than 60 years ago, the natural history and the long-term outcome are still being clarified. The patients with more severe gastroparesis often seek health care treatment in university medical centers specializing in gastrointestinal motility disorders and hence reports in the literature tend to be based on this population and may not be representative of the entire spectrum. The clinical manifestations of gastroparesis are heterogeneous but a significant proportion of patients end up with substantially poorer quality of life. In this article, the focus is on the clinical presentation and natural history of gastroparesis.

Gastroparesis

PURPOSE OF REVIEW

This review summarizes recent progress in the epidemiology, pathophysiology, and treatment of gastroparesis.

RECENT FINDINGS

The relationship between delayed gastric emptying and symptom pattern in gastroparesis and, related to it, its separation from functional dyspepsia remains an area of controversy and uncertainty. Pathophysiological studies have focused on the role of pyloric resistance and duodenal motility in generation of symptoms. In diabetic patients, glycemic control did not determine short-term changes in gastric emptying rate in type 2 diabetes, but poor glycemic control was a major risk factor for long-term development of gastroparesis in type 1 diabetes. At the cellular level, diabetic gastroparesis is characterized by loss of interstitial cells of Cajal (ICCs), and this is inversely correlated to the number of CD206+ macrophages, which are thought to have a protective effect on ICCs. Treatment trials have focused on dietary factors and a nasal spray formulation of metoclopramide. A meta-analysis of prokinetic studies found no association between symptom improvement and enhancement of gastric emptying in gastroparesis. Two controlled studies showed no benefit of tricyclic antidepressants (nortriptyline, amitriptyline) in idiopathic gastroparesis and functional dyspepsia with delayed emptying.

SUMMARY

The relationship between delay in gastric emptying, symptom pattern, and response to prokinetic therapy in gastroparesis is poor. In diabetes, gastroparesis is characterized by loss of ICCs, and this is inversely correlated to the number of CD206+ macrophages. Dietary interventions may help to alleviate symptoms. Tricyclic antidepressants do not provide symptomatic benefit to patients with idiopathic gastroparesis.

Influence of habitual physical activity on gastric emptying in healthy males and relationships with body composition and energy expenditure

Although a number of studies have examined the role of gastric emptying (GE) in obesity, the influences of habitual physical activity level, body composition and energy expenditure (EE) on GE have received very little consideration. In the present study, we compared GE in active and inactive males, and characterised relationships with body composition (fat mass and fat-free mass) and EE. A total of forty-four males (active n 22, inactive n 22; BMI 21-36 kg/m2; percentage of fat mass 9-42%) were studied, with GE of a standardised (1676 kJ) pancake meal being assessed by the [13C]octanoic acid breath test, body composition by air displacement plethysmography, RMR by indirect calorimetry, and activity EE (AEE) by accelerometry. The results showed that GE was faster in active compared with inactive males (mean half-time (t 1/2): active 157 (sd 18) and inactive 179 (sd 21) min, P< 0.001). When data from both groups were pooled, GE t 1/2 was associated with percentage of fat mass (r 0.39, P< 0.01) and AEE (r - 0.46, P< 0.01). After controlling for habitual physical activity status, the association between AEE and GE remained, but not that for percentage of fat mass and GE. BMI and RMR were not associated with GE. In summary, faster GE is considered to be a marker of a habitually active lifestyle in males, and is associated with a higher AEE level and a lower percentage of fat mass. The possibility that GE contributes to a gross physiological regulation (or dysregulation) of food intake with physical activity level deserves further investigation.

Idiopathic gastroparesis

Gastroparesis is a chronic symptomatic disorder of the stomach characterized by delayed emptying without evidence of mechanical obstruction. Idiopathic gastroparesis refers to gastroparesis of unknown cause not from diabetes; not from prior gastric surgery; not related to other endocrine, neurologic, rheumatologic causes of gastroparesis; and not related to medications that can delay gastric emptying. There is overlap in the symptoms of idiopathic gastroparesis and functional dyspepsia. Patients with idiopathic gastroparesis often have a constellation of symptoms including nausea, vomiting, early satiety, postprandial fullness, and upper abdominal pain. Current treatment options of dietary management, prokinetics agents, antiemetic agents, and symptom modulators do not adequately address clinical need for idiopathic gastroparesis.