Exploring Gastroparesis with Dr. Michael Cline

Podcast Transcript

Scott Steele: Butts N’ Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. So welcome to another episode of Butts N’ Guts. I'm your host Scott Steele, Chairman of colorectal surgery here in beautiful Northeast Ohio at Cleveland Clinic. We're very pleased to have Dr. Michael Cline who is the medical director of the multidisciplinary Gastroparesis Clinic here at the Cleveland Clinic. He's also a full professor of surgery at the Lake Erie College of Osteopathic Medicine. Mike, welcome to Butts N’ Guts.

Michael Cline: Thank you for an invitation.

Scott Steele: So we're going to talk a little bit about gastroparesis. But before we get there, let's take a big step back. A lot of people get bloating, a lot of people get “constipation” and they find their way to you. How do you take that big array of symptoms and whittle it down and say you have gastroparesis?

Michael Cline: My job is frequently to figure out who has a true motility disorder or a movement disorder, and who just has symptoms. You kind of divide it into two – functional and motility. I deal with the motility side. The functional side is more just medication, trying to cover up symptoms, laxatives, anti-gas products, those kinds of things. The vast majority of patients won't have gastroparesis. That's the more serious condition. Gastroparesis, by definition, if you look at the word gastro means stomach, paresis means paralyzed. It's basically a slow stomach or a stomach that doesn't move.

Scott Steele: What's the function of the stomach and what happens when you get a paralyzed stomach?

Michael Cline: The stomach’s job is to grind up the food you eat, and it has to do that effectively so that you can absorb the food in the small intestine. If it doesn't grind it up, then you aren’t going to get the nutrition out of the food, number one. Number two, if it doesn't grind it up and it sits there too long, it will actually typically come back up in the form of vomiting. That's the other symptom that a patient with gastroparesis frequently has. They have the nausea, they have vomiting, and another case symptom that I think people need to pay attention to is they fill up quickly – when they eat two bites of food and feel like they've eaten a Thanksgiving dinner, or they just avoid food altogether. We see a lot of patients who almost have a phobia of eating because they feel so miserable after they eat. They don't want to look at food.

Scott Steele: Some of the symptoms that you describe – gassy, bloating, maybe some upper abdominal pain or just kind of some generalized abdominal pain. What do you do to figure all this out?

Michael Cline: Typically you want to rule out anatomic or structural causes, ulcer disease, obstructions, partial obstructions. Fortunately, in the United States, we don't see a lot of gastric cancers, so we don't really have to worry about that too much. But you want to make sure the anatomy of the GI tract is OK. Then you get into the function and there are several ways to do that. Obviously, in the stomach, one is a radiology test that they can use where the patient actually eats a half a cup of scrambled eggs and two pieces of toast that are labeled with a tracer that they can pick up on a camera. And really there’s nothing involved in that other than getting a patient to eat it and then they lay there, and over a four-hour period of time they take pictures, and they can measure how much gets out of the stomach. 

Scott Steele: Does that hurt?

Michael Cline: No there's no pain involved. It is difficult for the patient because a lot of these patients, like I said, they don't want to eat. So they have to eat to do the test, and if they if they vomit the food back up the test is over.

Scott Steele: So what causes gastroparesis?

Michael Cline: The most common cause right now, and it's shifting, but the most common cause still we don't know. It's idiopathic, but very quickly with the epidemic of diabetes in the United States, diabetes is taking over. By far, diabetes is going to be the number one cause of gastroparesis. Typically those diabetics have had the disease for at least 10 years. And if we can say never in medicine, gastroparesis is never the first complication of diabetes. They usually have other things – neuropathy in their feet, their hands, eye issues, kidney problems, those kinds of things.

Scott Steele: Any other causes? 

Michael Cline: There are a couple of others. One is called Ehlers-Danlos syndrome (EDS), which is a connective tissue problem where your joints are really lax. People that are hyper flexible, I equate that to the super gymnast – the people that can bend themselves into pretzels. They're frequently involved with gastroparesis. Post-surgical patients, patients who have had to have surgery for acid reflux – the Nissen, as it's called – or other surgeries on their GI tract, especially their stomach, can create gastroparesis. And then the last category that is skyrocketing right now, and we don't know why, are young women in their 20s or even late teenage years, and it's autoimmune. Their bodies are attacking their own nerves and muscles in the gut. And we've just now been able to identify some antibodies in the bloodwork that we can figure that out and it is treatable.

Scott Steele: How common is gastroparesis, and how common are some of these other causes of them? Diabetes, obviously, we know is a major issue, but is gastroparesis common?

Michael Cline: It is common in the right population, and I think it's underdiagnosed in those people. Unfortunately, in the nation right now there's almost a two to two-and-a-half-year delay in making the diagnosis. So these patients have been sick for a couple of years prior to actually getting the formal diagnosis of gastroparesis. It's not going to be top on the list – top of the list is going to be anatomy problems, ulcers, narrowing in the GI tract, infections in the stomach, things like that. But if the patient has persistent symptoms, they really need to seek help and get some sort of motility test, some sort of movement test, to find out what's going on.

Scott Steele: As a patient, is there anything that I can do to kind of recognize I need to get further workup for this?

Michael Cline: In the diabetic population, the number one thing is sugar control. We know that even after the diagnosis, if you can control the sugars, frequently the symptoms are manageable without a lot of effort. So diabetic control, diabetic control, diabetic control, is the most important thing. Avoiding medications that slows the intestinal tract, especially with the epidemic of opioids out there right now. Narcotics stop the GI tract from working. And then pay attention to newer, changing symptoms if you've had them for a long time and they’re a nuisance, but they come and go. That's one thing. If they're there and they seem to be progressing, getting worse over time, go to your physician and say “hey I'm worried about this, can we do the testing?

Scott Steele: I'm a patient out there, and I tell my doc, hey listen, I am very worried about having gastroparesis, and I listened to this awesome podcasts out of the Cleveland Clinic. What can a patient expect when they come in to see you? Walk me through a visit, if I come to see you for gastroparesis. And then the second part of that is walk me through the testing you mentioned – the scrambled eggs – but what's the timing of this? What other tests can I expect to get if I come see you as a patient?

Michael Cline: To get into the multidisciplinary clinic, you have to have had at least a two- or four-hour emptying test – the egg test, as we call it. 

Scott Steele: So that's done ahead of time. For the providers that are listening out there and they're like, I think I got somebody out there, the providers are going to order that scrambled egg test. 

Michael Cline: And we did that primarily to separate out, like I said at the beginning, functional versus motility, because I was getting so many patients my clinic was overwhelmed with a lot of patients that didn't even have gastroparesis, they had just symptoms. A lot of them were diabetics and the sugars were in the 400s.

In our clinic, I'm very blessed to have ancillary staff – my nurse coordinator Natalie, she contacts every patient ahead of time, will spend typically somewhere around 45 minutes on the phone interviewing these patients, taking a detailed history, going over all of their history, getting all of their records. So we get all of that ahead of time so that when we see the patient in the clinic, it's very streamlined.

The one thing I love about our clinic, also, is it’s one location. The patient comes in and doesn't have to come around our big campus. They come into a room and we, as the physicians or caregivers, walk in and out. The patient is stationary. I had a lady that said she came from a town of 400 people and she was overwhelmed because Cleveland Clinic was three times the size of her hometown. For them not to have to move around is great. We will do a physical exam, we'll take the history, talk about the symptoms, talk about the connections with whatever disease they have – diabetes, especially, in all of the things we do. They are usually seen by myself, by one of the surgeons, if they need to see pain management we’ll get them involved, nutrition involved.

Natalie, my coordinator, does diabetic teaching, in the sense of diet or gastroparesis teaching, in sense of gastroparesis diet. And then there's a battery of blood tests we do immediately, looking for those weird causes of gastroparesis even in the diabetics. We want to make sure that there's not this autoimmune background or a hidden thyroid disease. We also have to get a handle on how good the sugar control is. That's where we start.

The test we then go to, which I think is probably the more important one, is called a smart pill or a wireless motility capsule. That pill was developed about 12 years ago and it is the only device we have available that can really measure from start to finish all the way through the GI tract. I think that's vital, and I think that's why we have the success we have, because we're finding out what's truly wrong with the entire intestine. We don't just pay attention to the stomach, and sometimes patients are confused by that. They come in thinking oh, I have gastroparesis, and then we do further testing and we go, guess what? It's gastroparesis plus this, or it's not even gastroparesis at all, it's a colon that is so slow it's backing everything up. That test is usually done at a later date because of insurance, we have to get it approved. Then typically we'll talk to them about medications – either medicines they've tried or medicines they’re presently on, and to see if we can tweak those or change those to get them better symptom control. 

Scott Steele: Are there any invasive tests, like a scope or anything that has to be done?

Michael Cline: Typically, all of these patients have had at least one scope. There was an elegant study done several years ago by a company called Optimum Life Science that showed a lot of these patients have had three, four, five scopes. And it's kind of like looking for the same thing over and over and over, nothing changed. Typically, unless the patient hasn't had one recently, then we'll set it up. Again, we try to do that ahead of time so that the patient’s visit is more concise because they are coming from a long distance. My coordinator will figure that out ahead of time and get them schedule for an EGD before they even get here.

Scott Steele: Before we talk about treatment, let's talk a little bit about complications or problems that gastroparesis can cause. You mentioned a really interesting fact to me that it could be years or months before people can actually get diagnosed with that. If left untreated, what are the complications, or is it something that can resolve or that can evolve out of gastroparesis.

Michael Cline: Typically, for the first 20-some years of my practice, typically it was starvation – these patients were starving. In fact, I carry a pen in my pocket that says “gastroparesis is starving for a cure.” In recent years, we've seen more and more obesity, which is interesting. Patients are unable to eat very much. So what they go to is processed carbohydrates. I call it the Twinkie diet. They go to a high fat, high carbohydrate diet because they need the calories, but it just packs on the pounds. Then add into the diabetes population eating all carbs and it's a disaster. It speeds up the diabetes complications. If they don't become obese, they tend to become very skinny, extremely malnourished. That's another thing that we deal with a lot before we even talk about treating the stomach – we have to treat their malnutrition or nothing's going to work. 

Scott Steele: Mike I want to circle back to something you said before. You made an interesting observation that some people have not only problems associated with a paralyzed stomach, but they can have their entire G.I. tract – kind of a pan G.I. tract dysmotility, or problems associated with having that. How often does that occur and where does gastroparesis fit into that? Do you treat one before the other, or are they all treated together, or are they all evaluated together? What happens for these groups of patients that kind of just their G.I. tract is not functioning? 

Michael Cline: We don't really know the total number of those patients. I will tell you we did a study here a year ago, published at a year ago in diabetics. Over 100 patients in the study – 70 percent of those that were labeled gastroparesis by using the egg test; 70 percent of the time when we did further testing using the wireless motility capsule – that smart pill - we found that frequently the rest of the gut didn't work also. Now that may be specific to diabetes because diabetes kind of attacks everything. We don't know about the other populations. That changes the ballgame because, obviously, then fixing the stomach alone isn't going to help these people. So your question about what do you do for those patients – I tend to pick out the worst. So if the stomach is horrible and the colon is mild, then we'll concentrate on the stomach and treat the colon with some medication. If the colon is horrific and the stomach is minimal, you know it may be abnormal, then you’ve got to fix the colon because nothing is going to move downstream. So it really is based more on what part is the most severe. If it's global dysmotility, as I like to call it, where everything doesn't work and it's all equal, then we're talking medication – and long-term medication.

Scott Steele: So let's jump right into treatment then.

Michael Cline: For mild cases we typically just use medications to cover up symptoms if they're not horribly ill, if they're tolerating a diet, they're maintaining a good weight, their sugars are under control. We'll use anti-nausea medicine, we will use acid suppression like the PPIs and things like that. You go from there, then you try to get into the motility drugs and, unfortunately, in the United States, we've lost a lot of very good motility drugs over the last decade due to side effects. So we're very limited in medications, and that makes our job difficult because there are very few drugs we can use routinely without a lot of potential risk. We've turned to the surgical cohorts, and that's why I like my multidisciplinary clinic because my surgeons and I work hand in hand. We communicate on every patient immediately after we see the patient, and we come up with a plan so that the patient knows kind of where we're moving forward.

One of the best advances in surgical approaches is recent, and that is a procedure called a POP. Our surgeons here have identified a way to do this which is much less invasive than the other way, which is called POEM. And we're getting excellent results. We've done well over 200 now since January, just started in January, and over 70 percent of them are getting back to normal gastric emptying. And I think the reason for that is because we do the work up beforehand and we make sure that it's an isolated stomach problem, not a small intestine not a colon problem. So there are great candidates for that.

Scott Steele: So for people who don't know what a POP and a POEM is, can you describe those a little bit?

Michael Cline: Sure. So POP stands for per oral, meaning down the mouth. Essentially, most of these patients have all had scopes EGD, stomach scopes. We use a stomach scope under anesthesia, so it's very comfortable. We make a small cut in the lining of the stomach, overtop of the muscle that regulates how food gets out. One of the issues in gastroparesis is that muscle isn't getting the signal how to work. It’s supposed to stay closed when you have food in there so the stomach can grind it up. Then the stomach sends a signal that says open – I’m going to empty. But that doesn't happen. So that muscle stays tight most of the time. And by opening it up, we don't make a full cut in it, but we open it so that allows the food the path of least resistance. We're well over 200 patients and we're over 70 percent successful. Unfortunately in the medical realm, I don't have a medicine that's 70 percent successful or we'd go with medication.

Scott Steele: Is there any sort of a stimulator or a pacemaker that you can put in for gastroparesis?

Michael Cline: Yes there is, we have a gastric pacemaker. It's very similar to the heart pacemakers, redesigned for stomachs. It worked very well. We used to use that as kind of the go-to procedure until we developed this other one. We've changed gears partly because this per oral is a lot less invasive. It's all done from inside the stomach – there’s no incisions. The pacemaker requires surgery; you have to implant the device and wires are attached to the stomach.  It works best in well controlled female diabetics, and less likely to work in the non-diabetic population. We don't really know why that is. Even the people that invented the device don't really know why. But we have used it both as primary therapy in some patients, as well as what we call rescue therapy, where they've already had a lot of things done to them and that's kind of the one thing they haven't had is the pacemaker. 

Scott Steele: For the patients out there that maybe are looking at “I want to get a POP or a POEM,” or something like that because they worry that if you just get them put on medications, you had said that they’re maybe not as useful with long-term results. Is this a progressive disease? Do you go from mild to moderate to severe? Does it help to go early in a surgical intervention, or do we need to just put on the brakes and say you're mild, you need to be put on medications, and this will normally get a little bit better?

Michael Cline: We don't really know that. One of the other categories, which I didn't mention early on, was actually the post viral group. There are patients who will get a flulike virus, and their stomachs will quit working. Those patients have a potential to go back to normal. So some of those that are mild we want to wait maybe even a year if they can put up with symptoms and are controlled with simple medications to see if it gets better. If it hasn't gotten better in a year or a year-and-a-half, it's probably not going to, and then we would move forward. We don't really know about the progression. I think a lot of that depends on the cause. If it's diabetes and the patient doesn't pay attention and isn't well controlled, yes it's going to progress, it's going to get worse. The other groups, the autoimmune group, we would expect to progress also if they're not treated.

Scott Steele: Final thoughts on gastroparesis. What's the take home message for the patients out there? 

Michael Cline: Take home message would be for the patients to be proactive. I think that it was over two years before patients are diagnosed. Ask early on, do you think I could have gastroparesis? Can I have that simple test – I call it the nuclear egg test – can I get that nuclear egg test? 

Scott Steele: So I like to end all the interviews with a couple of quick hitters to get to know you a little bit better. What's your favorite sport?

Michael Cline: Football.

Scott Steele: Favorite meal?

Michael Cline: Pizza.

Scott Steele: What's the last book that you read?

Michael Cline: Arnold Schwartz or Norman Schwarzkopf autobiography.

Scott Steele: What do you like about living here in Northeast Ohio in Cleveland? 

Michael Cline: I grew up, I was born and raised in Ohio. I lived all over the state and you get all four seasons. The winters are horrible, but the summers are great. And living close to Cleveland you’ve got everything you need – sports teams, music, arts.

Scott Steele: Well that's fantastic. For more information about gastroparesis as well as Cleveland Clinic's Digestive Disease and Surgery Institute, please visit clevelandclinic.org/digestive. To make an appointment with Cleveland Clinic digestive specialists, please call 216.444.7000. Mike, thanks so much for joining us on Butts N’ Guts. 

Michael Cline: Thanks for the invitation.

Scott Steele: That wrap things up here at Cleveland Clinic. Until next time, thanks for listening to Butts N’ Guts.