PWE-134 Management of gastroparesis: current practice in a tertiary centre

Abstract

Introduction Gastroparesis is a syndrome characterised by delayed gastric emptying in the absence of mechanical obstruction. The aim of this study was to assess consistency and adherence to guidelines of current practice and to evaluate the effectiveness of routinely implemented interventions in a large London tertiary centre. Methods A retrospective study was conducted by examining records of all adult patients with delayed gastric emptying, objectively measured by NM scintigraphy, between 2010–2017. Effectiveness was defined as evidence of symptomatic improvement either semi-quantitatively by the Gastroparesis Cardinal Symptom Index (GCSI) or by documented qualitative evidence from clinical records, before and after intervention. Our practice was compared to recommendations published by the American College of Gastroenterology in 2013. Results We identified 91 patients diagnosed with gastroparesis from 655 consecutive scans. Of these, 46 were excluded due to incomplete records. 55 patients were included: median age 48 (range 21–89), 67% female. Diabetes (40%) was the commonest cause; 40% of cases were idiopathic. Conservative management 34/55 (62%) patients had dietetic input with 16% requiring enteral nutrition. 17/55 (31%) of patients were taking a drug known to delay gastric emptying but stopped in only 12% of patients. Medical management 48/55 (87%) patients received prokinetics, including metoclopramide 28/55 (51%), domperidone 33/55 (60%) and erythromycin 19/55 (35%) with treatment duration specified in only 30%. No patients had documented GCSI. From qualitative records, 7/48 (15%) of these reported some benefit, while 20/48 (42%) had no effect and in 21/48 (44%) the effect was unknown. Intrapyloric Botox was administered in 25/55 (45%) of patients but results were not documented by GCSI. Nevertheless, 11/25 (44%) of patients reported some benefit. Additionally, 2 patients had pyloric dilatation and 1 feeding jejunostomy and venting gastrostomy. Conclusions The management of gastroparesis showed wide variations in practice in our institution. The lack of semi-quantitative assessment of the results of different interventions hindered evaluation of effectiveness. Conservative measures, including discontinuation of contributing drugs, were adopted only in a minority of patients. Prokinetics are widely used as first choice approach but treatment duration and stopping rules were not clearly established. Intrapyloric Botox injection showed subjective benefit in a proportion of patients, matching results of previous RCTs where placebo had similar benefit. Our study indicates the need for a more consistent and evidence-based management of gastroparesis. Dedicated outpatient clinics and internal protocols may help to achieve this task.