Online Health Chat with Michael Cline, DO

Wednesday, February 8, 2017 | Noon


Description

Gastroparesis is rapidly becoming a common diagnosis. This mysterious illness reduces the ability of the stomach to empty its contents. It can be especially detrimental to people with diabetes.

Gastroparesis is caused by damage to the vagus nerve. In its normal state, the vagus nerve contracts (tightens) the stomach muscles to help move food through the digestive tract. In cases of gastroparesis, the vagus nerve is damaged by diabetes and/or high blood pressure. This prevents the muscles of the stomach and intestines from working properly, which keeps food from moving from the stomach to the intestines. Gastroparesis is a chronic (long-lasting) condition. This means that treatment usually doesn’t cure the disease, but you can manage it and keep it under control.

About the Speaker

Michael Cline, DO, was appointed to Cleveland Clinic in 2012 with the department of Gastroenterology and Hepatology. Dr. Cline completed medical school at Ohio University College of Osteopathic Medicine in Athens, Ohio. His specialty is gastroparesis, and he offers treatments such as colonoscopy, gastric pacemaker, gastric pacer, and other general treatments and services for gastrointestinal diseases.


Let’s Chat About Gastroparesis


The Bottom Line

SamSeven: What is gastroparesis?

Michael_Cline,_DO: If you split gastroparesis into two words, it is by definition: Gastro (stomach) paresis (paralyzed) = slow stomach.

MapleLeaf: What are the symptoms of gastroparesis?

Michael_Cline,_DO: The typical systems are nausea, vomiting, abdominal pain, bloating and belching.

keroppi: Can gastroparesis cause pain on the left side, about an inch under your rib, that tends to worsen after eating? I've had this for years since I've been diagnosed. (Ultrasound, MRI and PET scan were done around that time, and were all normal.)

Michael_Cline,_DO: Gastroparesis can cause pain in some patients, but other sources including neurologic causes need to be ruled out.


Tests and Diagnosis

Fullmoon: Are their certain tests that will confirm I have gastroparesis? Are these tests accurate?

Michael_Cline,_DO: Basically, nuclear gastric emptying and a test called the wireless motility capsule are used. There can be a problem with the nuclear test, depending on how it is done. To be accurate, it really has to be a four-hour test done with scrambled eggs and nothing else.

ycco: Is a gastric emptying test not sufficient to diagnose gastroparesis? I had an abnormal one more than ten years ago and was told I just had "slow motility". Fast forward to three years ago when my health (not just my stomach) took a turn for the worse, I learned about gastroparesis, and it makes me wonder why I was never given the diagnosis back then, as I had the "classic symptoms" and an abnormal gastric emptying test. Thank you.

Michael_Cline,_DO: The gastric emptying test, if it is done the right way (four hours and with solid food), is one of the better tests we have. The problem is it does not coordinate with symptoms, so if it is abnormal, the numbers don't really mean anything.

holleywilliams: What is a good indicator of the need to move ahead to enteral feeding, a percent of weight loss over a defined period of time? Or would it be the length of time without adequate oral intake?

Michael_Cline,_DO: Typically, we don't want patients to lose more than 10 percent of their ideal body weight in three to six months. Another parameter is abnormal lab work suggesting malnutrition.

Fremont: Is the gastric emptying study the only way to diagnose gastroparesis? I've had it three times by three different providers. Two diagnosed mild gastroparesis, the third said it was normal (Mayo Clinic). I understand this test only represents how your stomach empties that particular day. I have pretty major symptoms and get so full so fast, can really only eat one meal and graze the rest of the day. I've also had obstructions just below the stomach. Is this related? Are there other tests that can accurately diagnose this condition?

Michael_Cline,_DO: Your history of having had multiple tests with various outcomes is fairly consistent with what we see regularly. That is one of the problems with the nuclear emptying test, especially when it’s borderline normal/abnormal, in proving whether or not someone truly has gastroparesis.

holleywilliams: Can you be more specific about what you mean by "global dysmotility" and "diffuse dysmotility”? What tests other than gastric emptying should be performed?

Michael_Cline,_DO: By global motility or diffused motility, I mean more than one area of the intestine. The most direct way to rule it out would be the smart pill. For more information, please read: Gastroparesis: ‘Smart’ Pill Uncovers This Mysterious Stomach Condition.

AOddone: What's included in a full gastroparesis/motility work-up?

Michael_Cline,_DO: There is a battery of lab tests looking for autoimmune antibodies that could be related to the motility disorder. Typically, patients will have an EGD or an x-ray of the intestine to rule out anatomic problems. If we are working-up a generalized motility problem, we would go to the smart pill test.


Multiple Maladies

AngelaOddone: What experience do you have treating patients whose gastroparesis is caused by Ehlers-Danlos syndrome in which there are multiple causes. These include poor vagal tone, stretchy tissues in the circulatory and gastrointestinal systems, mast cell activation syndrome causing inflammation, SIBO, leaky gut and endocrine issues such as adrenal fatigue and Graves or Hashimoto's resulting in hypothyroidism?

Michael_Cline,_DO: Ehlers-Danlos syndrome is not an uncommon cause of gastrointestinal dysmotility, and frequently leads to a diffuse motility disorder, not just gastroparesis. SIBO (small intestinal bacterial overgrowth) is a marker of small bowel dysmotility also.

DizzyGirl: I have gastroparesis related to POTS (postural orthostatic tachycardia syndrome) and EDS3 (Ehlers-Danlos syndrome type 3). The only thing that has been suggested for me is to "occasionally" take domperidone. I am a little nervous about taking it with my current drugs for POTS, and I really want something that will help me every day. Are there any other options or natural remedies that can be used to reduce the pain and nausea I have every day?

Michael_Cline,_DO: There are no real natural remedies that seem to be effective. It is very important when you have POTS and EDS3 that you rule out global dismotility.

sonjat: Good Morning. I was wondering if you see a lot of gastroparesis in patients with Sjogren's or other autoimmune conditions. Also, what symptoms do you typically see with this condition? Would excessive bloating and constipation be included? Would this condition cause shortness of breath or "air hunger" symptoms? Thank you.

Michael_Cline,_DO: The gastroparesis is directly linked to the autoimmune disease. We have to make sure, especially in someone who has constipation, that the entire gut is not involved. Typically, gastroparesis does not affect breathing or the heart. The autoimmune disease can, but gastroparesis won't.

keroppi: Is SFN (small fiber neuropathy) a known cause of gastroparesis? Is there any way to prevent the progression of gastroparesis if you don't know the cause? What if you just have idiopathic SFN, or mito issues?

Michael_Cline,_DO: There is an association with SFN and gastroparesis. Typically, SFN has to be fairly advanced to get gastroparesis, and unfortunately, there is no way to prevent it from affecting your stomach.

vateton: I was diagnosed with gastroparesis after a very slow stomach emptying test (eight percent vs. 50 percent normal), but I also have confirmed small fiber neuropathy. Is it possible that the diagnosis is incorrect, and I should consider dysautonomia? What tests will help me differentiate these diseases?

Michael_Cline,_DO: I think this will be best worked-up by a neurologist who specializes in small fiber neuropathy, because gastroparesis can be present in both.

WaveWolf: I am a T9 incomplete paraplegic and also have diagnoses of multi-systemic sarcoidosis (cause of paralysis), RA and several other autoimmune conditions. I have steroid-induced diabetes, which is managed with a strict diet and a chromium supplement. I eat small meals, but try to include fiber as part of managing my bowels and avoiding constipation. In eight years, I have not achieved a regular bowel program. I cannot maintain stool consistency, have a lot of gas and pain (from gas or from partial obstruction), but do not have much nausea or any vomiting unless I eat too much fat, too much food, or sweets. Should I be tested for gastroparesis?

Michael_Cline,_DO: Given the complexity of your history, it is best served to see you in the clinic. Appointment information will follow the chat.


Diet and Digestion

A-Aron: What are the basics of a gastroparesis diet?

Michael_Cline,_DO: It includes low-fat and low-fiber foods and frequent, small meals. Depending on the severity of symptoms, we use liquid nutrition as well.

DizzyGirl: Is the low-FODMAP diet at all beneficial for people with gastroparesis?

Michael_Cline,_DO: I am not a fan of the low-FODMAP diet. It goes in and out of favor, but had never really shown to do much for gastroparesis. It is also a very restrictive diet and is very difficult for patients to stay on long-term.

DizzyGirl: For mild gastroparesis linked to POTS and EDS3 (I am able to eat smaller amounts of solid foods, but have lots of pain and nausea), are there any "diets" that can help?

Michael_Cline,_DO: Stick to a low-fat, minimum fiber diet.

lgmac: How can my obese husband lose weight and keep his bowels moving? He bulks up with kidney beans and rye/wheat bread to keep his bowels going now. He has internal hemorrhoids, gastroparesis, paruresis, history of DVT, and CIDP, and won't eat any "rabbit" food. He says he can't take Miralax. Help!

Michael_Cline,_DO: When a person has gastroparesis, keeping the bowels moving is difficult because the diet becomes primarily carbohydrates. The rabbit food is much harder to digest, and if the stomach is not emptying it, it could make things dramatically worst. I would recommend a nutrition evaluation for weight loss along with a full gastroparesis/motility work-up followed by treatment of whatever is found.

liesel: I am a 77-year-old female. I live a very healthy life; I eat healthy and exercise daily. I do have heart disease and high blood pressure and take metoprolol ER 25mg and Losartan 50mg. I do NOT have diabetes. As long as I can remember, I have had problems with constipation. For the last year, I have constant difficulty with emptying completely. I always have the feeling that I need to go again. I go at exactly the same time every morning, right after one cup of coffee. But in the evening, I have the urge again and feel as if I am constipated to the point that I have been using glycerin suppositories, sometimes with good results and other times with more pain than stool. I do take a daily dose of Miralax and also drink plenty of water. Is there anything else I could be doing?

Michael_Cline,_DO: Given the complexity of your history, it is best served to see you in the clinic. Appointment information will follow the chat.


Talking Treatments

vateton: I started monthly IVIG infusions for small fiber neuropathy caused by sarcoidosis and found it positively impacted my gastroparesis. Is this ever used expressly for this purpose?

Michael_Cline,_DO: IVIG has now been shown to be effective in gastroparesis when there is a co-existing autoimmune disorder. We are using it more and more for gastroparesis.

Agurene: Dysautonomia and gastroparesis often appear together in patients. What is your recommendation for treating or managing gastroparesis in dysautonomia patients who cannot be exposed to neurotoxins in certain medications such as Reglan? What natural options are there – diet, supplements, lifestyle changes, etc. – that could help such patients?

Michael_Cline,_DO: Dysautonomia and gastroparesis frequently occur together. In dysautonomia patients, we have to rule out a global dismotility. We need the entire intestine, not just the stomach. There are very few natural substances that have been looked at. Ginger is used to help with gas, and there is a natural supplement called Imerogest that has been shown to be of some benefit to people. In dysautonomia, the biggest thing is to make sure we have the right diagnosis.

bafke: Is there any treatment that would help the vagus nerve work as close to normal as possible?

Michael_Cline,_DO: Unfortunately, not at this time. There is some research going on across the world in what's called vagal pacing.

DizzyGirl: I've heard some people mention that they have used Iberogast to manage their gastroparesis symptoms. Is that something you think would work or would recommend?

Michael_Cline,_DO: It is not well-studied, but has shown in case reports to be effective. There is really no harm in trying it. It's not going to hurt you, but it would really be trial-and-error process to see if it works for you.


Medication Messages

Iodine: What are some effective treatments for someone with EDS-related overall GI dysmotility, including gastroparesis?

Michael_Cline,_DO: When someone had general dismotility, the medical treatment options are limited. Two specific drugs we have available through the FDA are domperidone and Propulsid. They are drugs that have been designed to move more than just the stomach.

AOddone: Is domperidone FDA approved now? It wasn't a few years ago.

Michael_Cline,_DO: Domperidone is not FDA approved. We do have, however, through the FDA, a program to prescribe domperidone in the United States. It will not be covered by insurance and requires frequent office visits every eight weeks for the first year you're on the drug.

crystalclear: After being diagnosed with gastroparesis ten or 12 years ago, I took omeprazole every day until I read in 2016 that it could be linked to an increased risk of dementia. I have since read that those test results were inconclusive. What is your opinion about those test results? For a while (about a year), I seemed to be doing OK without the omeprazole, until about a month ago when the bloating returned. Should I risk taking the omeprazole again? It's been ten or 12 years since I've seen the gastroenterologist. Once one has been diagnosed with gastroparesis, do they always have gastroparesis?

Michael_Cline,_DO: Once you've been diagnosed with gastroparesis, it is very rare for it to go away. However, it may fluctuate in how severe the symptoms are. The article on dementia showed an association between Prilosec and dementia, but not a cause. In addition, that article used elderly patient and not young patients. So, the best answer would be to use the omeprazole as needed or as infrequently as you can to control the symptoms.


Diabetes Dimension

keroppi: Does gastroparesis affect hypoglycemic patients? Is it likely to cause more hypoglycemic episodes if it takes longer for food to digest and be converted to energy? If you're experiencing a hypoglycemic episode, will it take longer to correct and bring the blood sugar back to normal if digestion is slowed down?

Michael_Cline,_DO: It will make blood sugar control more difficult if you have gastroparesis, and it can activate hypoglycemia. So, it can mess with blood sugars significantly.

BEACHBABIES: Why and at what "stage" is gastroparesis linked to diabetes?

Michael_Cline,_DO: Typically, people with types 1 and 2 diabetes will have had diabetes for more than ten years prior to diagnosis. The more uncontrolled the diabetes, the higher the risk. One important factor with diabetes is the better the blood sugar control, the better the control of gastroparesis symptoms. Gastroparesis is almost never the initial complication of diabetes. Typically, the patient will have other neuropathy.


Specific Circumstances

gatorfrog: Six years ago, I had a subtotal colectomy because my food would not travel through. I don't know if that was gastroparesis or not, but since then, my food takes forever to digest, especially if I eat meat. I have Type 2 diabetes and am wondering what should I be doing or eating because of that? Is there something I should be looking out for and/or not eating? Thank you for any help.

Michael_Cline,_DO: Given the problems with the colon, the fact that you’re still experiencing symptoms and you have the risk factor of Type 2 diabetes, it will be a good idea to get the smart pill study to look at the motility movement of the entire GI tract.

keroppi: In the first few years of my gastroparesis diagnosis, my stomach puffing out after eating was one of the main symptoms. Once the food was digested, usually by the next morning, my stomach would be flat. Now, years later, I'm still waking up with the bloated/puffy belly, though it's smaller than the night before, it's still there, and the bigger the meal I've eaten the night before, usually the bigger the "morning belly”. Is it possible for gastroparesis to progress like this, where the food seems undigested even if it's been 17 hours after eating? I know it can be progressive in other ways, and I was wondering if this was the start? (I have mitochondrial dysfunction and presumed SFN.)

Michael_Cline,_DO: It is possible for it to progress, but more importantly, a work-up needs to be done to evaluate for more than just gastroparesis.

linbow: I had a Nissen Fundoplication (NF) in 2007. In 2009, I began losing weight (80 pounds total in almost a year), and was told my vagus nerve was damaged and was diagnosed with gastroparesis. In 2015, my heartburn and reflux returned, and I had a second NF done in June 2017. My stomach never seems to feel comfortable. Is this mainly due to my diet?

Michael_Cline,_DO: When there is post-surgical gastroparesis, the best approach would be further surgery on the stomach to allow it to empty faster. Typically, medication therapy is not very effective in post-surgery gastroparesis. Your condition probably is not diet related. A high-fiber diet will make symptoms worse, but you’re not going to manage the gastroparesis just by diet.


Clinic Connection

DizzyGirl: What is your normal regimen for patients you see with mild gastroparesis?

Michael_Cline,_DO: First, we do lab work and frequently follow up with tests to rule out causes of gastroparesis. Then, we will institute the four-stage diet with our multidisciplinary clinic. The patients will be evaluated for surgical options and pain management if they have pain issues. Also, we will consider behavioral medicine for non-pharmacological treatment and various medications based on other co-existing diseases and personal health.


Closing

That is all the time we have for questions today. Thank you, Dr. Cline, for taking time to educate us about Gastroparesis.

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