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Maagontledigingsstoonissen Ad Masclee

Maagontledigingsstoonissen Ad Masclee. Aaa aaa a a. Maagontledigingsstoornissen. Onderliggende problematiek Diagnostiek Nieuws ?

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Maagontledigingsstoonissen Ad Masclee

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  1. Maagontledigingsstoonissen Ad Masclee Aaa aaa a a

  2. Maagontledigingsstoornissen • Onderliggende problematiek • Diagnostiek • Nieuws ? • Behandel algoritme

  3. Gastroparesis • Chronic symptomatic disorder of stomach - delayed gastric emptying - in absence of mechanical obstruction

  4. Casus 52 jarige vrouw verwezen ter analyse van: • zwaar gevoel in maagstreek na maaltijd • misselijkheid en soms braken • afvallen, 3kg, door minder intake • Klachten typisch voor gastroparese?

  5. Gastroparesis symptoms • Symptoms: nausea, vomiting, satiety, bloating, discomfort and pain • Symptom scores: PAGI-SYM and GCSI • Malnutrition • Weight loss Horowitz et al Eur J Nucl Med 1991

  6. Gastric emptying and symptoms score Hasler et al NGM 2013

  7. Casus 52 jarige vrouw verwezen ter analyse van: • zwaar gevoel in maagstreek na maaltijd • misselijkheid en braken • afvallen, 3kg, door minder intake • Klachten typisch voor gastroparese? • Aanvullende info ?

  8. Gastroparesis FD idiopathic DM diabetic Other: post-surgery systemic disorder CIPO ?

  9. Gastroparesis • Chronic symptomatic disorder of stomach - delayed gastric emptying - in absence of mechanical obstruction • Prevalence • Population: 2-4% • Delayed gastric emptying in DM: 30-40% • Delayed gastric emptying in FD: 20-30%

  10. Idiopathic gastroparesisclinical features • 90% females, meanage 40 yrs • 50% acute onset • infectiousprodromes : prognostic factor ++ • Overweight: 45% • Presenting symptoms: nausea, vomiting, pain • Anxietyanddepression > 50% • IBS Rome III : 70% Parkman GE 2011

  11. Post antireflux surgery: vagus nerve dysfunction N=137 , LUMC, MUMC

  12. Opioid use in gastroparesis W.L. Hasler et al, Clin Gastroenterol Hep, 2019

  13. Gastroparesis classification • Grade1: MILDsymptomseasilycontrolled, normalweight, minor dietarymodifications • Grade 2: COMPENSATED moderate symptoms, medication, diet • Grade 3: GASTRIC FAILURErefractorysymptomsmalnourished, metabolicderangementshospitaladmissions, enteralnutrition Abell et al NGM 2006

  14. Gastroparesis: outcome Gastroparesis: outcome GP Consortium, CGH 2015

  15. Casus 52 jarige vrouw verwezen ter analyse van: • zwaar gevoel in maagstreek na maaltijd • misselijkheid en braken • afvallen, 3kg, door minder intake • Klachten typisch voor gastroparese? • Aanvullende info ? • Diagnostiek ?

  16. Scintigraphy: standardisation • Patient factors smoking, medication, hyperglycemia, hormonal status • Meal large variability • Image acquisition AP geometricmean, 0-1-2-4 hr post meal • Interpretation Abell et al. Am J Gastro 2012

  17. Gastric emptying: octanoic acid breath test

  18. Gastric emptying : techniques Rao et al NGM 2011

  19. Gastric emptying : techniques Rao et al NGM 2011

  20. Gastroparesis: management • Treatment underlying disease • Optimize metabolic condition • Dietary measures • Prokinetics and anti-emetics, new drugs ? • Botulinum toxin ? • Gastric Electrical Stimulation (GES) ? • G-POEM ? • Treatment algorithm

  21. Management: dietary measures • Frequent small meals • Generousfluid intake (withsolids) • Low fat, low fibre • Nutritional support: liquid formulas • PEG- duodenal extension • Jejunostomy ( endoscopic or surgical) • Enteralnutrition • Parenteralnutrition: never indicated !

  22. Management: prokinetics • Metoclopramide • Domperidone • Erytromycin • New drugs?

  23. Gastroparesis: erytromycin

  24. Future perpectives gastroparesis: • Relamorelin: ghrelin agonist • Velusetrag: 5 HT 4 agonist • Revexipride: 5 HT 4 agonist • Prucalopride: 5 HT 4 agonist • Camicinal: motilin agonist

  25. Prucalopide in Gastroparesis Carbone et al Am J Gastroenterol 2019 a Aa aa Aa aa aa

  26. Botulinium Toxin in Gastroparesis Maastricht UMC+ experience Gastroparesis, diet and prokinetics failed Documented gastroparesis Botox intrapyloric 500 U (Dysport) N=40 Symptom response 35% Weight response : 65% Octanoid acid breath test: Antroduodenal manometry: No predictors of response Smeets et al , Gastroint. Dis 2019

  27. Gastric electrical stimulation in gastroparesis

  28. Therapeutic strategies in gastroparesis Diet and prokinetics Step 1 Success 58% Failure 42% Step 2 Gastric rest + EN Success 20% Failure 22% PEG-J Step 3 Success 8% Failure 14% G-POEM Step 4 Success ? Strijbos et al. NGM June 2019

  29. De heer W. 71 jaar 2013: zuurbranden, slokdarmontsteking 2014: anti-reflux operatie: Nissen fundoplicatie 2014: klachten zijn over, maar …. kan niet meer eten! 2015: 20 kg afgevallen, conditie ↓ door “vertraagde maaglediging” hobbies: wandelen en tuinieren, gaat niet meer…. 2015: voeding via PEG sonde , conditie ↑, tevreden, maar …

  30. De heer W. 71 jaar 2013: zuurbranden, ernstige slokdarmontsteking 2014: operatie: Nissen fundoplicatie 2014: klachten over, maar …. kan niet meer eten 2015: 20 kg afgevallen, conditie ↓ door “gastroparese” hobbies: wandelen, tuinieren gaan niet meer 2015: voeding via PEG, conditie ↑, tevreden, maar …

  31. Alg. Dagblad 17 april 2018:

  32. Gastroparese: Onbekend, Onderschat, Onbemind, Test: goed (4 uur meten) en goedkoop, Gastric failure: enorme impact ! Behandel ondervoeding tijdig ! Houdt vast aan stappenplan

  33. Gastroparesis Literatuur: • B Stein e.a. J ClinGastroent 2015; 49: 550-8 • Tack e.a. CurrOpinGastro 2017 33: 446-54 • Strijbos e.a. NGM, juni 19 • Camilerri et al Am J Gastroenterol 2013, guideline

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