Gastroparesis from an Acid Reflux Specialist Perspective
Gastroparesis is a chronic motility disorder affecting the stomach and duodenum and characterized by delayed gastric emptying in the absence of mechanical obstruction. Patients with gastroparesis complain of bloating, nausea, vomiting, pain and heartburn. Gastroparesis may cause acid reflux since gastric emptying is impaired. Furthermore, many patients with acid reflux disease reports belching, bloating, pain, nausea and food regurgitation; Symptoms are commonly associated with gastroparesis. The underlying pathophysiology connecting gastroparesis and acid reflux disease remains poorly understood. It is important, however, to maintain a high index of suspicion for a potential gastrointestinal motility disorder when evaluating patients for acid reflux disease.
At Houston Heartburn and Reflux Center, patients presenting for acid reflux evaluation may undergo an esophageal manometry study to check for esophageal dysmotility and a gastric emptying study to check for delayed gastric emptying. Both esophageal dysmotility and delayed gastric emptying contribute to acid reflux disease.
If gastroparesis is diagnosed in the setting of acid reflux disease patients are counseled prior to proceeding with treatment. Gastroparesis is a chronic and difficult disease to manage and treat. There are no medications effective enough to restore gastric motility. Surgical options are limited with poor outcomes reported with subtotal gastrectomy. Traditionally, a gastric drainage procedure is added to gastroparesis patients undergoing Nissen fundoplication surgery for treatment of acid reflux disease. Typically a pyloroplasty is performed with acceptable outcomes. Gastric Bypass surgery has been recently proposed, in one study from the Cleveland Clinic, as a good option for gastroparesis in the morbidly obese patient. Gastric bypass surgery is an excellent treatment for acid reflux too. However, the remnant stomach may cause symptoms of bloating and pain since gastric secretion tends to accumulate in the paralyzed stomach.
A better alternative is a procedure I developed few years ago called longitudinal gastrectomy with a duodeno-jejunostomy. Resecting the gastric fundus seems to increase gastric emptying and draining the duodenum with a duodeno-jejunostomy promotes duodenal emptying. Preserving the antrum is important during longitudinal gastrectomy as it represents the gastric pump and promotes emptying. I published the first longitudinal gastrectomy and duodeno-jejunostomy as a case report in the journal of Surgery For Obesity And Related Diseases. I performed a second one on a young patient with idiopathic gastroparesis. Both patients did very well and were followed for up to one year after surgery.
Gastrointestinal motility affects many functions in the body and contributes to many diseases like acid reflux, diabetes and obesity. Gastric motility patterns are highly coordinated and still poorly understood. Future research will shed more light on the effect of gastric motility on acid reflux disease.