S3596 Chronic Abdominal Pain After Gastrojejunostomy: An Unexpected Outcome

Abstract

INTRODUCTION: Gastroparesis is a neuromuscular disorder of the upper gastrointestinal (UGI) tract. Diabetes is the most common known etiology, accounting for 20–30% of cases. Other major causes include medication adverse effects, neuromuscular disease, idiopathic, and post-surgical gastroparesis (PSG), which has a prevalence of 0.4-5%. We present a case of PSG treated with botulinum toxin (Botox). CASE DESCRIPTION/METHODS: A 56-year-old man with uncontrolled diabetes (HbA1c 14.2), hypertension, and small bowel perforation status post gastrojejunostomy in 2014 presented with nausea, vomiting, and diffuse postprandial abdominal pain. Initial medical management with pro-motility agents: erythromycin and metoclopramide were unsuccessful. CT scan abdomen was negative for acute pathology. EGD revealed a patent gastrojejunostomy with normal pyloric contractions. No retained food, ulcer, or gastritis was found. A gastric emptying study was negative for gastroparesis, showing a functional gastrojejunostomy. The patient underwent EGD with Botox injection into the pylorus and gastrojejunal anastomosis (Figures 1 and 2). He was also started on low dose nortriptyline. He remained symptoms free at 2 months follow up. DISCUSSION: PSG is thought to have a multifactorial etiology including dysfunction of the parasympathetic system after vagotomy and lack of duodenal motilin release after duodenal resection. After one year, a significant percentage of patients develop compensatory neurostimulation to adapt to their new anatomy. Gastrojejunostomy predisposes to slow emptying from the gastric remnant and delayed transit in the denervated efferent limb. Therefore, less than 25 cm resection is often recommended to avoid stasis. Botox injection for refractory PSG has some evidence of efficacy. One trial showed an average response rate of 43% for 5 months, with a target on quality of life. Whereas another demonstrated a 55% improvement at 6 weeks post-procedure with positive outcomes in the motility of solid food. Additionally, non-selective serotoninergic inhibitors (NSRI) such as nortriptyline (with the least anticholinergic effect) have shown promising effects at low doses for patients with refractory gastroparesis. Our patient likely had a combination of diabetic gastroparesis and PSG, which did not respond to medical therapy. We demonstrate the effective use of botulinum injection in combination with NSRI.Figure 1.: Pylorus, blood is seen post Botox injection.Figure 2.: Patent gastrojejunostomy and antrum.