When You Have A Hammer In Your Hand, Everything Around You Starts Looking Like A Nail
The patient is a 34-year-old male with epigastric pain and belching following food intake. He rarely had heartburn, sore throat, chronic cough, or food regurgitation. He also denied vomiting. He responded poorly to PPI therapy. His workup included a negative pH Bravo study, and upper endoscopy showing no distal esophagitis or irregular Z line. He had a widened hiatal opening but no obvious axial displacement on the EGD pictures he shared with me. His treating physician decided to perform a TIF procedure (Transoral Incionsless Fundoplication) for presumed acid reflux disease that is poorly controlled with PPIs.
Following TIF, the patient epigastric pain persisted and he started developing severe postprandial bloating. A gastric emptying study showed delayed gastric emptying suggestive of gastroparesis. He was then started on Erythromycin and Reglan with minimal symptom improvement. An upper endoscopy with pyloric sphincter Botox injection was then performed but with no symptom relief. He presented to my office for a second opinion. The patient has occasional heartburn but the bloating and epigastric pain are the main complaints.
Gastroparesis and acid reflux disease may have overlapping symptoms. Gastroparesis may also contribute to acid reflux disease especially in the presence of a hiatal hernia. Both GERD and gastroparesis can be present at the same time further complicating the treatment approach. It is crucial however not to mistaken a gastroparesis case for acid reflux. The differentiation starts with history taking. As in this case, the patient symptoms were more suggestive of gastroparesis than acid reflux. The lack of response to PPI and the negative pH bravo study further supports gastroparesis. All patients with more bloating and epigastric pain related symptoms compared to heartburn and food regurgitation have gastroparesis until proven otherwise. All patients with recurrent vomiting are less likely to have acid reflux disease and other diagnostic testing should be considered.
The treatment of gastroparesis is quite challenging. Traditional medications are not effective most of the time and are associated with side effects like tardive dyskinesia. Newer medications are being tested. A ghrelin agonist is being developed by Pfizer and is already in stage 2 trials. The treatment however of gastroparesis like that of obesity and diabetes is multifactorial and one medication controlling one pathway is unlikely to work. Our understanding of gastric emptying remains limited and further research in this field is needed to better treat this vexing problem. I used a longitudinal gastrectomy with duodeno-jejunostomy for treatment of severe refractory gastroparesis in two patients and it worked very well. Resecting the gastric fundus promotes gastric emptying and may be of therapeutic value in gastroparesis cases. Similarly, a Nissen fundoplication increases gastric emptying and when combined with a pyloroplasty, it may be a good option for patients with severe acid reflux disease and delayed gastric emptying. I personally prefer the use of gastric fundus resection to promote gastric emptying and resolve acid reflux. Obviously, a prospective randomized study is desperately needed to answer these questions and develop clear guidelines for treatment of a growing problem like gastroparesis.