Botox Injection: A Salvage Therapy for Diabetic Gastroparesis in a Patient With Prior Gastrojejunal Anastomosis

Abstract

Gastroparesis (GP) is a disorder of gastric motility resulting in delayed gastric emptying. Diabetes mellitus is the most commonly recognized systemic disease associated with gastroparesis. With limited medical options, use of pre-pyloric botulinum toxin A(BT-A) has shown to be effective and is offered as a salvage therapy in cases of refractory GP. A 42 year old woman with past medical history of type I diabetes mellitus (DM), diabetic neuropathy, severe DGP presented with abdominal pain, nausea and vomiting for five days associated with early satiety and postprandial fullness. The physical exam was remarkable for epigastric tenderness. Labs showed blood sugar of 388 mg/dL, hemoglobin A1C of 9.4 and metabolic alkalosis. She has a long standing history of severe DGP refractory to previous medical therapy. She has failed a trial of gastric pacemaker and feeding jejunostomy tube multiple times. She had transient response to gastrojejunostomy. Gastric emptying study revealed severe GP (greater than 35% activity in stomach at 4 hours). A decision to inject botulism toxin endoscopically was made considering non response to medical and surgical therapy. An upper endoscopy was performed which demonstrated a normal looking gastrojejunal anastomosis and no endoscopic evidence of stenosis, stricture or mass in the pylorus. 200 units botulinum toxin was diluted in 10 ml of saline. The area around the pylorus was successfully injected circumferentially with 8 ml of diluted botox solution and area around gastro-jejunal anastomosis was successfully injected with 2 ml of diluted botox solution with no immediate complications. Patient was subsequently started on PO diet which she tolerated well with clinical improvement in her symptoms. Antroduodenal dyscoordination is found in DGP, where the actions of the pylorus are not coordinated with that of the antrum. Thus, the antrum contracts against a closed pylorus, preventing emptying of gastric contents. The use of BT-A injection to relieve symptoms and improve quality of life in patients with severe gastroparesis refractory to standard therapy is a safe and inexpensive treatment before considering surgery. Use of botox was particularly challenging in this case as patient had prior gastrojejunal anastomosis. This case highlights the success of botox injection in treatment of diabetic gastroparesis in a challenging patient with prior gastrojejunal anastomosis.Figure: Prepyloric channel circumferential botox injection.