Case of the Week: Recurrent Gastroparesis Symptoms

Jane is a pleasant 51-year-old female with history of idiopathic gastroparesis diagnosed in 2008. She underwent a subtotal gastrectomy with Billroth 2 gastrojejunostomy and insertion of feeding tube jejunostomy in 2009. Post-operatively the patient had difficulty tolerating per-oral diet for about 5 months. She was placed on Reglan and erythromycin and maintained on tube feeding. After 5 months she improved, and her PO diet was successfully advanced to regular. Patient continued to do well for about 8 years. In 2016 she started experiencing epigastric pain, abdominal fullness and bloating as well as a burning sensation extending from the epigastrium to the throat level. An upper endoscopy was performed, and patient was found to have a friable and inflamed gastric mucosa as well as an irregular Z line. She was diagnosed with bile gastritis and decision was made to convert her B II gastrojejunostomy to Roux-en-Y gastric bypass. The gastric bypass was done laparoscopically, and patient recovered without complications. Her symptoms however did not improve. She continued to have the same burning sensation, constant bloating exacerbated by food intake and epigastric pain. She denies vomiting or food regurgitation. When she presented to my office, she was maintained on high dose PPIs, Ranitidine, Carafate, Domperidone, and Welchol.

The patient may have had an element bile gastritis, but her symptoms were most likely due to recurrent gastroparesis. I have no explanation for the initial improvement in in her gastroparesis symptoms 5 months after subtotal gastrectomy. She has most likely developed a duodenal pacemaker to drive intestinal motility. For unknown reasons, the pacemaker failed after several years and her gastroparesis symptoms (fullness, pain and burning sensation) recurred. Bile gastritis may cause a similar symptom profile, but bile gastritis, unlike gastroparesis, responds very well to a Roux-en-Y gastric bypass. Jane did not respond to gastric bypass. She most likely has recurrent gastroparesis symptoms and in the absence of a stomach there is very little I can do from a surgical point of view. This particular case demonstrates one more time that gastric bypass surgery is not a solution for gastroparesis. Subtotal gastrectomy is not an option either. The stomach antrum and lesser curvature must be preserved in gastroparesis. After resecting the greater curvature above the antrum, gastric motility improves. I have performed this procedure on a dozen of severe gastroparesis patients with 100% success rate. An antrum based gastric pacemaker restores normal gastric emptying and results in complete symptom resolution. Resecting the antrum in a subtotal gastrectomy burns an important bridge for treatment of gastroparesis. Of note, the burning sensation extending from the epigastric area to the mouth is not uncommon in gastroparesis patient. It is not secondary to acid reflux and is different from heartburn. Patients typically report a burning sensation in the oral cavity that may involve the lips sometimes that does not respond to acid suppressant medication. This sensation, in addition to pain, are likely secondary to sensory abnormalities involving the gastro-intestinal sensory neurons.