Danielle C. Spree

Gastric Electrical Stimulation Is an Option for Patients with Refractory Cyclic Vomiting Syndrome

Background/Aims Cyclic vomiting syndrome (CVS) is a disabling migraine variant manifesting as severe episodes of nausea and vomiting and often refractory to many therapies. Gastric electrical stimulation (GES), which can reduce nausea and vomiting in gastroparesis, may provide symptomatic relief for drug-refractory CVS. This study assessed the utility GES in reducing the symptoms of CVS and improving the quality of life. Methods A one-year, non-randomized, clinical study was conducted. Eleven consecutive patients with drug refractory, cyclic vomiting syndrome based on Rome III criteria and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), underwent treatment with temporary GES (Temp GES) and permanent GES (Perm GES). Post-treatment follow up was done up to one year after permanent gastric electrical stimulation therapy. Results Total symptom score decreased by 68% and 40% after temporary and permanent GES therapies, respectively. Hospital admission events significantly decreased to 1.50 (± 1.00) events from 9.14 (± 7.21) annual admissions prior to treatment with permanent GES. Vomiting episodes fell by 83% post Temp GES and 69% after Perm GES treatments. Mucosal electrogram values also changed after temporary stimulation. Conclusions In a small group of drug-refractory CVS patients, treatments with temporary and permanent GES significantly reduced the severity of gastrointestinal symptoms and frequency of hospital admissions.

Cyclic vomiting syndrome: A common, underrecognized disorder

Purpose: To increase recognition and present symptom assessment strategies for treating cyclic vomiting syndrome (CVS). Data sources: Clinical experience, a range of pediatric, gastroenterological, emergency medicine research, survey, and literature review reports on CVS. Conclusions: Improved efforts to recognize, diagnose, and treat CVS will help patients manage their symptoms and may reduce both the morbidity and costs of hospitalizations associated with this illness. Implications for practice: If promptly diagnosed and appropriately treated, CVS episodes can be aborted. Patients inappropriately treated must often be hospitalized because of complications associated with symptoms. Lifestyle changes, prophylactic and abortive migraine therapy, and supportive care are important to prevention.

Gastric Stimulation is an Option for Patients With Refractory Cyclical Vomiting Syndrome: One Year Follow up

Background: Post-surgical gastroparesis (PSG) develops in up to 10% of patients who undergo intentional or inadvertent vagotomy and in up to 50% of patients undergoing surgery for gastric outlet obstruction. Dumping syndrome is also a possible outcome from these surgeries. Aim: The aims of this study were to: 1) describe the clinical features of patients presenting with PSG symptoms; 2) identify surgeries associated with PSG; 3) distinguish PSG from a possible Dumping Syndrome. Methods: Medical and surgical history, symptoms assessment (PAGI-SYM,PAGI -QOL, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and standardized 4-hour radionuclide gastric emptying test (GET) on patients with at least 12 weeks of gastroparesis (GP) symptoms were performed. Data were analyzed from the ongoing NIDDK GP Registry. All results are presented as percent or mean ± SD. Results: Out of 571 patients, 23 (4 %) qualified as having PSG symptoms. Of these 19 (83%) were F; mean age 48.0±13.2 years; mean BMI 24.7 ±6.5 (61% had a BMI ≤ 24). The mean symptoms duration was 6 years and onset of GP symptoms was associated with the following surgeries: Nissen Fundoplication (52%), partial gastric resection (22%); myotomy or esophago-gastrectomy (9% each); and stomach stapling and vagotomy (4% each). 52% of patients had been hospitalized in the past year and nausea with abdominal pain was the major indication for 78% of these admissions. 52% were on prokinetics, 78% on antiemetics, 78% on PPI / H2 blockers and 26% were on narcotics. None of the patients underwent Botox and 1 had Enterra therapy. The results of GET separated patients with PSG symptoms into: Group A-17(74%) with delayed GETmean value of 43.3 %± 26% retention at 4h (min-14; max -100% ), and 9 (53%) of them had severely delayed gastric emptying (>35% retention at 4h) and Group B6 (26%) without delayed GET, with a mean of 5.3% food retention at 4 h (min-1, max-7%) and with 2 (33%) of these patients meeting the criterion for Dumping Syndrome with ≤30% retention at1h. Overall, the highest mean PAGI-SYM score was for nausea 3.7 ± 1.3(max 5) and early satiety at 3.7±1.3. 17% of all studied patients had severe depression by BDI, 30% had severe STAI score. The average PAGI-QOL score was 2.7±1.1; with the poorest QOL for the diet sub-score (1.6±1.2). There were no statistical differences in symptoms or psychological parameters between the two groups. Conclusions: 1) In the setting of post-gastric and -esophageal surgeries, symptoms associated with delayed, normal or rapid emptying of the stomach are clinically indistinguishable and only GET could guide further medical and therapeutic approaches 2) Nissen Fundoplication is now the major surgery associated with PSG symptoms and could be attributed to “accidental” vagal nerve injury during surgery.

S2077 Gastric Electrical Response to Different Stimulation Parameters via Intraoperative Egg Recordings

Background and Aims: Acupuncture or electroacupuncture (EA) has been applied for treating chemotherapy-induced emesis with limited success. Two major problems with EA include infrequent application of EA and suboptimal stimulation parameters. The aims of this study were to investigate the feasibility of EA using chronically implanted electrodes and the effects of EA with different parameters on cisplatin-induced emesis in rats assessed by pica (intake of kaolin) that has been validated as a surrogate of emesis in rats. Materials and Methods: Under anesthesia, 19 SD rats were chronically implanted with a pair of electrodes at bilateral acupoint PC6 as follows: A 3mm tip of the exposed wire (serving as an electrode) was inserted into the acupoint and the connecting wire was firstly fixed in the muscle layer around the acupoint, then tunneled subcutaneously to the back of the neck and finally exited and protected for EA. After recovery and appropriate acclimation, the rats were treated using a 3×3 Latin Square cross-over design in which each rat received a sequence of 3 treatments in one of 3 assigned orders. The treatments included the following: EA1: 20Hz, 0.6ms, 2mA and continuous stimulation; EA2: 10Hz, 1.2ms, 2mA and continuous stimulation; Control: no stimulation. During each treatment, cisplatin 6mg/kg was injected intraperitoneally at 3PM during the first day and the rats received with one of the three treatments while staying at a rat restrainer for 3 hrs from 6pm-9m daily for 2 days. During the other periods, the rats were housed in their individual cages. There was an interval of 2 weeks between the two consecutive treatments. Results: 1) The implanted electrodes remained secured at the acupoints without infections. 2) Cisplatin induced substantial kaolin intake as well as reduced food intake and body weight; Treatment with EA1 significantly reduced kaolin intake on the first and second day after cisplatin in comparison with the control (first day, EA1 vs. Control, 1.0±0.2 vs.1.9±0.3g, p=0.017; second day, 0.4±0.2 vs.1.1±0.3g, p= 0.010); 3) Treatment with EA2 had no effects on kaolin intake after Cisplatin. Conclusions: Electrical stimulation via chronically implanted electrodes at acupoints is feasible. That is, EA may be performed chronically and continuously using implantable electrodes and pulse generator. EA at PC6 with appropriate parameters is able to reduce Cisplatin-induced kaolin intake in rats, suggesting an ameliorating effect on chemotherapy-induced emesis. The significant difference in the performance of EA with different parameter sets demonstrates the importance of parameter optimization in the application of EA.