Gastroparesis, or delayed gastric emptying, has many origins and can wax and wane depending on the underlying cause. Not only do the symptoms significantly alter quality of life, but the clinical consequences can also be life threatening. Once a patient develops protracted nausea and vomiting, providing adequate nutrition, hydration, and access to therapeutics such as prokinetics and antiemetics can present an exceptional challenge to clinicians. This article reviews the limited evidence available for oral nutrition, as well as enteral and parenteral nutritional support therapies. Practical strategies are provided to improve the nutritional depletion that often accompanies this debilitating condition.
Key points
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Patients with gastroparesis (GP) are at high risk for nutritional compromise, not only because of chronic nausea and vomiting, which can result in poor intake, but also because of potential anatomic changes such as gastric resection or bypass.
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Target weight should be set for patient and intervention provided before a patient becomes severely malnourished.
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Use of parenteral nutrition (PN) should be reserved only for those patients who fail enteral feedings.
Introduction
A 57-year-old woman presents to the gastrointestinal (GI) clinic with myositis, poorly controlled diabetes mellitus (DM), nausea, vomiting, dehydration, and a 10-lb (4.5-kg) unintentional weight loss. GP is confirmed by gastric emptying study. Oral diet modification failed with continued nausea, vomiting, further weight loss, and aggravated glycemic control due to steroid therapy. On her third admission and a weight loss of 30 lb (210 to 180 lb [95.3 to 81.6 kg]), the decision was made to place a percutaneous endoscopic gastrostomy (PEG) with a jejunal extension (PEG/J) for enteral nutrition (EN), hydration, and medication delivery. Feedings went well initially in the hospital, but the patient continued to eat and drink after discharge when she felt better, resulting in 2 more admissions due to failed therapy and poor glycemic control. In an effort to give her some relief and keep her hospital free, the patient was strongly encouraged to stop eating and drinking anything other than a few ice chips, and she was miserable enough that she agreed. Tube feeding goals were met nocturnally, glycemic control improved, and she was discharged without readmission. She then followed up in GI nutrition clinic to ensure nutritional goals continued to be met.
Gastroparesis
GP, defined as delayed gastric emptying for greater than 3 months, is documented by a delayed gastric emptying study in a patient devoid of mechanical or functional obstruction, can be profoundly incapacitating. This debilitating process alters one’s ability to work, attend school, or carry out other normal daily activities. GP can affect the patient’s emotional, mental, and social well-being, as well as the body’s ability to function normally; basically, it compromises life. Eating becomes a chore and is not pleasurable, and as a result, weight loss and compromised nutritional status are common in moderate to severe cases. Furthermore, in those with DM, glycemic control can become difficult. The following outlines a practical approach to nutritional care of the patient with GP from nutritional assessment and oral dietary intervention to, finally, nutritional support.
Introduction
A 57-year-old woman presents to the gastrointestinal (GI) clinic with myositis, poorly controlled diabetes mellitus (DM), nausea, vomiting, dehydration, and a 10-lb (4.5-kg) unintentional weight loss. GP is confirmed by gastric emptying study. Oral diet modification failed with continued nausea, vomiting, further weight loss, and aggravated glycemic control due to steroid therapy. On her third admission and a weight loss of 30 lb (210 to 180 lb [95.3 to 81.6 kg]), the decision was made to place a percutaneous endoscopic gastrostomy (PEG) with a jejunal extension (PEG/J) for enteral nutrition (EN), hydration, and medication delivery. Feedings went well initially in the hospital, but the patient continued to eat and drink after discharge when she felt better, resulting in 2 more admissions due to failed therapy and poor glycemic control. In an effort to give her some relief and keep her hospital free, the patient was strongly encouraged to stop eating and drinking anything other than a few ice chips, and she was miserable enough that she agreed. Tube feeding goals were met nocturnally, glycemic control improved, and she was discharged without readmission. She then followed up in GI nutrition clinic to ensure nutritional goals continued to be met.
Gastroparesis
GP, defined as delayed gastric emptying for greater than 3 months, is documented by a delayed gastric emptying study in a patient devoid of mechanical or functional obstruction, can be profoundly incapacitating. This debilitating process alters one’s ability to work, attend school, or carry out other normal daily activities. GP can affect the patient’s emotional, mental, and social well-being, as well as the body’s ability to function normally; basically, it compromises life. Eating becomes a chore and is not pleasurable, and as a result, weight loss and compromised nutritional status are common in moderate to severe cases. Furthermore, in those with DM, glycemic control can become difficult. The following outlines a practical approach to nutritional care of the patient with GP from nutritional assessment and oral dietary intervention to, finally, nutritional support.
Nutritional assessment
Initial and ongoing nutritional assessment and intervention are critical aspects of care of the patient with GP. Thorough assessment distinguishes those patients who need simple dietary changes from those who are so malnourished that nutritional support is justified. For example, a patient who develops nausea while eating the usual 3 large meals per day may not require supplemental calories, but rather smaller, more frequent meals. In contrast, the patient with severe GP who has significant vomiting after intake of clear liquids may require gastric decompression and jejunal feeding to provide not only nutrients, fluids, and medications but also symptom relief.
Unintentional Weight Loss
Unintentional weight loss over time is one of the most basic yet undeniable indicators that a patient’s nutritional status is in trouble. Comparing a current weight (once the patient has been rehydrated) with the patient’s usual weight and documenting the percentage of total weight loss over time can stratify the degree of nutritional risk and help guide therapy. Use of an ideal body weight instead of a patient’s actual weight is not recommended, as it may overestimate or underestimate the degree of nutritional risk.
Glycemic Control
In patients with DM, it is often difficult to sort out which came first, poor glucose control or GP. Regardless, good glycemic control (especially any wide swings in glucose control) is necessary for improving gastric emptying, nutrient utilization, and preventing catabolism. In addition, out-of-control DM may be the primary reason the patient is losing weight. Glycemic control can be monitored by patient glycemic records and periodic measurement of glycosylated hemoglobin (HbA1C) level.
Bowel Habits
Constipation can worsen the symptoms of GP, and chronic constipation may be a sign of a more generalized intestinal dysmotility. When practitioners justifiably pay so much attention to the upper gut in patients with chronic nausea and vomiting, they sometimes tend to overlook the lower tract; in fact, this author’s experience is that while the gastroenterologist focuses on the GP, the primary care physician is taking care of the bowels, and sometimes their interventions are at odds with one another. For example, the addition of fiber bulking agents to help with constipation only exacerbates delayed gastric emptying. Identifying normal bowel habits is also important, particularly with inpatients who are on bed rest and perhaps pain medications, because during a hospitalization, physicians often prescribe nightly docusate to the patient who normally uses Miralax (polyethylene glycol 3350) twice a day at home.
Nutritional intervention—oral diet
Prospective controlled trials regarding dietary contributions in this patient population are near nonexistent; hence, diet therapy has been devised based on known emptying characteristics of protein, fat, and carbohydrate and emptying of liquid foods versus solids. Other than 2 small studies evaluating large versus small food particle size and symptom response in patients with insulin-treated DM, single-meal trials in heterogeneous populations with GP or normal volunteers and patient surveys are all that has been published to date. Diet therapy and nutritional supplementation therefore must be individualized, taking into consideration the underlying cause of the GP such as postsurgical process versus underlying chronic disease course. See Appendix 1 for one institution’s sample diet for GP (more complete and other versions available at www.ginutrition.virginia.edu under patient education materials).
Smaller, More Frequent Meals
The larger the volume of food ingested, the slower the emptying, and both caloric density and bulk (fiber) contribute to this. Early satiety is a frequent complaint; hence, smaller amounts of food at frequent intervals during the day is the first nutritional intervention that should be implemented. Six or more small meals/snacks during the course of the day may be needed for patients to take in enough food to meet their nutritional needs.
Fat
Physiologically, it is well known that fat slows gastric emptying, and patients with GP are therefore often advised to restrict fat in their diet. However, eliminating fat also removes a significant calorie source and requires patients to eat larger volumes of food if they are to meet nutrient needs and stop weight loss. It may be that solid foods high in fat are the culprit; clinically, this author has found that fat-containing liquids are often well tolerated and can be a valuable source of nutrition for the patient with GP.
Decreasing Fiber
High-fiber foods and stool-bulking agents delay gastric emptying, leading to early satiety and symptom exacerbation in those with GP. Some patients may even present with a gastric bezoar as the first indication that they have GP. Small-bowel bacterial overgrowth (SBBO) is a known risk factor in those with dysmotility disorders, and frequent use of proton pump inhibitors, which is not uncommon in this population, further aggravates the problem. Consuming a high-fiber diet, or using a fiber-containing tube feeding formula in those requiring enteral nutritional support, can intensify abdominal distension, gas, bloating, reflux, and diarrhea. For those patients who have formed a bezoar, fiber avoidance is especially important.
Another dietary intervention under investigation in dysmotility disorders is the avoidance of FODMAPs, or f ermentable o ligo- d i- m onosaccharides and p olyols. FODMAPs are highly fermentable by gut bacteria, as well as highly osmotic, and they too can further accentuate symptoms in those with GP. They are not only found in certain foods but are also added to some enteral formulas (fructooligosaccharides [FOS] are one of them) in addition to many liquid medications for flavorings, including sugar alcohols such as sorbitol and xylitol. Their effect can be additive, so that a patient on enteral feedings with a fiber-containing formula and liquid medications may seem intolerant to the tube feeding, when in fact the problem is purely the FODMAP/fiber load they are receiving.
Liquids Versus Solids
As liquid emptying is usually preserved in patients with GP, transitioning to more liquid calories in the diet may help patients meet their nutritional needs, especially during exacerbations. It may help in some patients to have them start the day with some solid food but then consume more liquid-type meals as the day progresses and the feeling of fullness increases. As mentioned earlier, fat-containing nutritional drinks are often well tolerated.
Particle Size
In the normal setting, a major function of the stomach is to grind food into smaller particles (trituration) initiating digestion. This function may be impaired or lost in the patient with GP, so a focus on chewing foods well may help to compensate and aid in this process to improve emptying. Two small studies have demonstrated symptom improvement when ground foods versus solid food meals were provided. It should be noted that with good dentition, grinding food before ingesting would seem unnecessary, yet good dental care can be difficult for these patients. Not only can frequent vomiting alter enamel and weaken teeth but also when just getting off the couch is a chore, it can be hard enough just to make it to physician appointments and easy to delay dental treatment. Although pureed foods have not been studied, if grinding food into smaller particles has been shown to decrease symptoms, pureeing food may be an option for patients having difficulty tolerating even ground foods. With a good blender, anything can be pulverized if adequate liquid is added.
Patient Positioning
Positioning or use of gravity may also play a role in helping patients tolerate an oral diet. If turning on one’s right side is necessary to undergo a barium swallow, then patients may get some relief by sitting upright for 1 to 2 hours after a meal or by even going for a gentle walk.
Special consideration—vitamins and minerals
Patients who have had prolonged nausea and vomiting leading to poor nutritional intake are at risk for multiple nutrient deficiencies. In a large multicenter study evaluating food frequency questionnaires, patients with GP from idiopathic or DM cause were found to have diets deficient in calories and numerous vitamins and minerals. When eating nearly ceases, taking vitamins and minerals generally does too. Patients with GP due to a previous gastric surgery are at even greater risk for nutrient deficiencies because of anatomic changes and alterations in nutrient utilization. For example, patients with a subtotal gastrectomy are more at risk for iron and vitamins B 12 , D, and E deficiencies; gastric bypass surgery, a procedure that creates malabsorption, significantly increases the risk for an even wider range of nutrient deficiencies. See Box 1 for those nutrients that may warrant particular attention, although any patient with significant and unintentional weight loss is at risk for pan-nutrient deficiencies.
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Vitamin D (25-OH vitamin D)
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Serum vitamin B 12 /methylmalonic acid (methylmalonic acid in those at high risk for small bowel bacterial overgrowth (SBBO), as vitamin B 12 can be converted to biologically inactive form in the gut before absorption)
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Iron/ferritin (in non–acute phase setting)
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Folate: elevated serum folate level may be suggestive (but not diagnostic) of SBBO in patients with a dysmotility disorder. Bacteria in the small bowel synthesize folate, which is then absorbed into the bloodstream, resulting in elevated serum levels.
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Vitamin E (gastric resection 2 years post-op)
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Thiamine: gastric bypass or others with vomiting greater than 3 weeks
It may be prudent to provide supplements to patients with malnutrition or known poor nutritional intake with a therapeutic vitamin and mineral supplement for an empiric length of time (∼4 weeks) until they are eating normally again, or, if requiring enteral feedings, until goal delivery rate is achieved. Chewable or liquid supplements may be better tolerated in some than the tablet form; for others, a smaller dose (such as one-half tablet, twice a day) may work better; remember, any is better than none in those who need it. Avoid giving multiple, individual supplements, as this not only gets costly but is also time consuming and compliance may decrease.
Nutritional support
Patients unable to maintain a healthy weight despite oral diet modifications are candidates for specialized nutritional support. A defined target weight should be set with the patient; if a patient is unable to achieve this or drops below this weight, nutritional support should be initiated. Indications for enteral access and nutritional support include the following :
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Unintentional weight loss of greater than 5% to 10% over 3 to 6 months
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Inability to meet weight goals
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Weight falls to less than what was agreed on by patient and physician as time for intervention
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Need for gastric decompression
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Frequent hospitalizations, with or without weight loss
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Dehydration
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Diabetic ketoacidosis
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Refractory nausea/vomiting
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Requiring access for consistent delivery of medications, hydration, and nutrition
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Overall quality of life is unsustainable or plain failure to thrive
Enteral Nutrition
In patients who cannot consistently meet their nutritional requirements or regain the much needed lost weight, EN support is recommended. EN is associated with fewer infections and complications, is less expensive, and is less labor intensive for nursing staff and caregivers compared with PN. The selection of the best enteral access device varies between health care institutions and continues to be a source of debate owing to the lack of prospective trials evaluating the various approaches. Vented and nonvented options are available. For those with uncontrolled vomiting, a venting port indicates that there is a separate gastric port to drain off gastric secretions in an effort to give the patient relief from ongoing vomiting, although careful monitoring is needed if this route is chosen because of the potential risk for hypochloremic metabolic alkalosis. Nonvented tubes do not offer such an option. See Box 2 for enteral access options. A more in-depth discussion on various enteral access techniques is available elsewhere. Regardless of the type of access chosen, jejunal feeding has been shown to improve symptoms, glycemic control and reduce the need for hospitalization.
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