When Eating Doesn`t Work

11/05/2015
What is Gastroparesis?
Delayed gastric emptying in the absence
of obstruction
When Eating Doesn’t
Work
Gen Med A Team
Mike Starr, Margot Nash, Renata Kukuruzovic, Connor Hensey
Elly Green, Nat Soszyn
Symptoms
Differential Diagnoses
• Vomiting
– Usually large volume consisting of food
•
•
•
•
Abdominal pain
Weight loss
Early satiety
Postprandial fullness
Causes in Adults
•
•
•
•
•
•
•
•
Diabetes Mellitus
Thyroid dysfunction
Neurological disease
Prior gastric/bariatric surgery
Autoimmune disorders
Drug-induced
GORD
Post-viral
•
•
•
•
•
Oesophagitis
Peptic Ulcer Disease
Cyclical vomiting
Rumination syndrome
Intestinal obstruction
Causes in Kids
• Post-viral
• Drug-induced
• Post-surgical
• Associated with neurological
comorbidity
1
11/05/2015
Diagnosis
Management
• Gastric emptying study
– Radiolabeled meal ingested and percentage
of radioactivity calculated at various times
– Considered delayed if retention is >90% at
1hr, >60% at 2hrs, and >10% at 4hrs.
• Pillars of treatment
– Management underlying disease
– Correction of fluid/electrolyte imbalance
– Alleviation of symptoms
– Maintenance of optimal nutritional status
• Breath test
– Stable nonradioactive C-isotope meal given,
ratio of metabolised CO2 exhaled measured
– Less accurate, but less radiation
Management
Management
• Dietary/lifestyle modification
• Medications
– Prokinetics
• Metoclopramide, Domperidone, Erythromycin
– Frequent small volume meals
– Low fat
– low non-digestible fiber
– Avoid carbonated beverages
– Avoid lying down for 1-2 hrs after a meal
– Antiemetics
• Ondansetron, metoclopramide, prochlorperazine
– PPIs
– Botox
• Injected into pylorus
Management
References
• Surgical
•
American College of Gastroenterology, gastroparesis guideline
•
Saliakellis E, Fotoulaki M. Gastroparesis in Children. Annals of
Gastroenterology (2013) 26, 1-8.
– Placement of a gastrostomy or Jejunostomy
tube
– For refractory cases
2
11/05/2015
Calculations:
For a 4 month girl (6 kg):
WHO Daily Energy Requirement:
645 kcal/day
Infant Formula:
60 – 75 kcal/100 mL
Pepti Junior 66 kcal/100mL
Daily requirement:
860 - 1075 mL/day
Discussion
Cow’s milk protein intolerance
• How much is enough?
• If not enough, what would you do?
• Would supplementation in this situation be
useful?
• Reproducible adverse reaction of an immunological
nature induced by cow’s milk protein
• Incidence: 1.8 – 7.5% in first year of life (usually
present < 6 months)
• Classification:
– IgE mediated (immediate-onset)
– Non-IgE mediated (delayed-onset)
3
11/05/2015
References
Non-IgE mediated CMPI
Diagnosis and Management
• Symptoms of non-IgE mediated CMPI can be nonspecific and diagnosis of CMPI in some infants may
be controversial
• Formula-fed infants with persistent irritability and
suspected CMPA
– Change to eHF for 2–4 weeks
– Trial of AAF may be appropriate if no significant improvement
within 4 weeks
• In infants who respond to dietary elimination, rechallenge after 4–6 weeks to confirm the diagnosis
Food for thought:
References
When can you change from EHF to cow’s milk formula?
• Natural history of CMPI – resolves during childhood
(usually by age 5)
• Time to tolerance varies greatly
1.
2.
3.
• If the diagnosis of CMPA is confirmed, maintain on
elimination diet using a therapeutic formula for at
least 6 months or until 9 to 12 months of age
4.
• “Milk ladder” approach
5.
WHO Guidelines: Feeding and nutrition of infants and young children
Allen KJ, Davidson GP, Day AS, Hill DJ, Kemp AS, Peake JE, et al:
Management of cow's milk protein allergy in infants and young
children: an expert panel perspective. J Paediatr Child Health 2009,
45(9):481–486.
Fiocchi A, Brozek J, Schunemann H, Bahna SL, von BA, Beyer K, et al:
World Allergy organization (WAO) diagnosis and rationale for action
against Cow's milk allergy (DRACMA) guidelines. World Allergy Organ J
2010, 3(4):57–161
Venter C, Brown T, Shah N, Walsh J, Fox AT. Diagnosis and
management of non-IgE-mediated cow’s milk allergy in infancy - a UK
primary care practical guide. Clinical and Translational Allergy.
2013;3:23. doi:10.1186/2045-7022-3-23.
Luyt, D., Ball, H., Makwana, N., Green, M.R., Bravin, K., Nasser, S.M. et
al, BSACI guideline for the diagnosis and management of cow’s milk
allergy. Clin Exp Allergy. 2014;44:642–672
4