Pyloric Stent & Pyloroplasty

Pyloroplasty is surgery to widen the opening in the lower part of the stomach (pylorus) so that stomach contents can empty into the small intestine (duodenum). It is used for treatment for gastroparesis. A pyloric stent is used as a bridge between the stomach and the small intestine.

Source: http://www.slideshare.net/shafaatullahkhatt/peptic-ulcer-ahn

"The pylorus is a thick, muscular area. When it thickens, food cannot pass through. The surgery is done while you are under general anesthesia (asleep and pain-free).


If you have open surgery, the surgeon:

Makes a large surgical cut in your belly to open the area.

Cuts through some of the thickened muscle so it becomes wider.

Closes the cut in a way that keeps the pylorus open. This allows the stomach to empty.

Surgeons can also do this surgery using a laparoscope. A laparoscope is a tiny camera that is inserted into your belly through a small cut. Video from the camera will appear on a monitor in the operating room. The surgeon views the monitor to do the surgery. During the surgery:

Three to five small cuts are made in your belly. The camera and other small tools will be inserted through these cuts. Your belly will be filled with gas to allow the surgeon to see the area and perform the surgery with more room to work.The pylorus is operated on as described above.


Why the Procedure is Performed
Pyloroplasty is used to treat complications in people with peptic ulcers or other stomach problems that cause a blockage of the stomach opening.


Risks for anesthesia and surgery in general are:
Reactions to medications
breathing problems
Bleeding
blood clots
infection


Risks for this surgery include:
Damage to the intestine
Hernia
Leakage of stomach contents
Long-term diarrhea
Malnutrition
Tear in the lining of nearby organs (mucosal perforation)


Before the procedure, tell your surgeon:
If you are or could be pregnant
What medicines you're taking, including medicines, supplements, or herbs you bought without a prescription


During the days before your surgery:
You may be asked to stop taking medicines that make it hard for your blood to clot. Some of these are aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and clopidogrel (Plavix).
Ask your surgeon which drugs you should still take on the day of the surgery.
If you smoke, try to stop. Ask your surgeon for help quitting.


On the day of your surgery:
Follow instructions about not eating and drinking.
Take the medicines your surgeon told you to take with a small sip of water.
Arrive at the hospital on time.
After the Procedure
After surgery, the health care team will monitor your breathing, blood pressure, temperature, and heart rate. Most people can go home within 24 hours.

Outlook (Prognosis):
Most people recover quickly and completely. The average hospital stay is 2 to 3 days. Most people can slowly begin a regular diet in a few weeks.

Alternative Names
Peptic ulcer - pyloroplasty; PUD - pyloroplasty; Pyloric obstruction - pyloroplasty

References: Chan FKL, Lau JYW. Peptic ulcer disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 53.

Teitelbaum EN, Hungness ES, Mahvi DM. Stomach. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 48."

Source: http://medlineplus.gov/ency/article/002922.htm

Source: http://www.frauenwg.info/pages/v/vagotomy-and-pyloroplasty/

"Gastroparesis: Looking at a Breakthrough


John Clarke says that a stent to bridge the stomach and small intestine may play a big role in treating patients with gastroparesis in the future.

Patients with gastroparesis don’t get a lot of good news from their physicians. Risky medications or gastric surgery have typically been the go-to solutions for people whose stomachs don’t empty properly.

Those less-than-ideal options prodded gastrointestinal motility specialist John Clarke and colleagues to a new approach: Rather than cut the pyloric valve, why not insert a stent to bridge the stomach and small intestine?

Now, results from three stent placements are promising. The write-up is soon to be published in the journal Endoscopy.

'I think this technique could potentially play a big role in the treatment of gastroparesis,' says Clarke, clinical director of the Johns Hopkins Center for Neurogastroenterology.

All of the patients that Clarke describes showed dramatic reductions in symptoms. A 15-year-old boy with chronic nausea and vomiting, for example, had endured unsuccessful trials of erythromycin, metoclopramide, domperidone and promethazine. He showed significant improvement after undergoing transpyloric stent placement. A 54-year-old man with idiopathic gastroparesis who also didn’t respond to medication experienced a complete recovery.

A third patient had minor complications that were remedied with relative ease. 'Her stent migrated out and her pain came back,' says Clarke. Things were once again fine after the team repositioned the stent.

Technically, stent placement is pretty simple, says Clarke, and the risk appears to be minimal. 'If it doesn’t work, you just take it out,' he says. 'And, as opposed to gastric stimulation, which is done through surgery, this is just endoscopy. Although this sounds a bit unconventional, its safety looks better than anything else we have.'

Clarke explains that advances in stent technology played a key role in his team’s decision to move ahead with the pyloric stents.

Recently, the field’s seen creation of a flexible, covered stent 'that you can place via the endoscope,' Clarke says. 'The stent is metallic, but covered with a silicone lining so that the mucosa won’t grow into it. The stent was approved to treat obstructions, but hadn’t yet been used to treat gastroparesis.'

The number of patients with a gastroparesis diagnosis is on the rise, Clarke says. 'I’d estimate that 30 percent of my clinical practice comprises patients with gastroparesis. And only about 30 percent of them are diabetic. Most of the patients I see have idiopathic disease.'

In the next few months Clarke expects to begin a larger trial of the stent placement.

'This is an experimental therapy, and the long-term benefits are unclear,' he explains. 'However, given the few options currently available and the risk associated with those options, endoscopic stent placement may have a key role to play in managing this complex disorder.'”

Source: http://www.hopkinsmedicine.org/news/publications/inside_tract/inside_tract_summer_2013/gastroparesis_looking_at_a_breakthrough


The pyloric stent is used to stretch out the pylorus so that food can pass through easier. Sometimes, balloons may be used to help stretch it out and to help spasms. The video below goes into detail about it.


http://www.youtube.com/watch?v=vrU-6RX1_lg

"Johns Hopkins GI Doctors Use Endoscopy to Place Transpyloric Stent 'Could Play a Big Role' in Gastroparesis Treatment

Physicians at Johns Hopkins say they are encouraged by early results in three patients of their new treatment for gastroparesis, a condition marked by the failure of the stomach to properly empty its contents into the small intestine. In an article published online today in the journal Endoscopy, they describe how the placement of a small metal stent in the stomach can improve life for people who suffer from severe bouts of nausea, abdominal pain and vomiting that accompany the condition.

John Clarke, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine, and the article’s lead author, used an endoscope to place a pyloric stent in three patients with delayed gastric emptying. The pylorus is the part of the stomach that connects to the small bowel.

'I think this new technique could play a big role in the treatment of gastroparesis,' says Clarke, who also is clinical director of the Johns Hopkins Center for Neurogastroenterology. 'Though it sounds a little bit unconventional, the safety of it may be better than anything else we have out there.'

Clarke says recently developed flexible, silicone-covered metal stents have already been approved to treat some gastrointestinal obstructions, but until now have not been used to treat gastroparesis.

Typically, patients with gastroparesis don’t get a lot of good news from their physicians. Stomach surgery or risky medications such as erythromycin and metoclopramide have been the go-to treatments for the condition, which can have serious health and quality-of-life consequences.

'There are few FDA-approved options for gastroparesis patients,' Clarke says. 'The only medicines that are approved have a number of adverse effects associated with them.'

The National Institutes of Health estimates that 5 million Americans live with gastroparesis, a condition in which the contents of the stomach empty into the intestine slowly or not at all. Symptoms, including reflux, become chronic.

Using an endoscope, Clarke placed a self-expandable, coated metallic stent across the three patients’ pyloric channels, holding the channels open and allowing the patients’ stomachs to empty normally.

All three patients showed dramatic reductions in symptoms, Clarke says. One was a 15-year-old boy with chronic nausea and vomiting who had endured unsuccessful trials of erythromycin, metoclopramide, domperidone and promethazine. A second was a 54-year-old man with idiopathic gastroparesis who also didn't respond to medication, but had complete recovery after his stent placement. In a third patient, the stent migrated out of place and her pain came back, but after replacing it, the pain eased, Clarke reports. All were treated at The Johns Hopkins Hospital.

Clarke says the stent placement procedure isn't difficult.

'Technically it’s pretty simple, and the risk appears to be minimal; if it doesn’t work, you just take it out,' he says. 'Gastric surgery to stimulate emptying is riskier than endoscopy.'

The number of patients diagnosed with gastroparesis is on the rise, Clarke says. 'I’d estimate that 30 percent of my clinical practice comprises patients with gastroparesis.'

Clarke says a larger clinical trial, which he expects to begin in the near future, is needed to provide longer follow-up of results and to identify which patients are likely to benefit the most from stents. “Our hope is that stent placement may become either a primary treatment option or a bridge technology to determine who can best benefit from surgery to improve stomach emptying.”

Source: http://www.hopkinsmedicine.org/news/media/releases/_johns_hopkins_gi_doctors_use_endoscopy_to_place_transpyloric_stent

Endoscopic Treatment of Gastroparesis
Thomas R McCarty and Tarun Rustagi

Abstract
Gastroparesis has traditionally been a largely medically managed disease with refractory symptoms typically falling under the umbrella of the surgical domain. Surgical options include, but are not limited to, gastrostomy, jejunostomy, pyloromyotomy, or pyloroplasty, and the Food and Drug Administration approved gastric electrical stimulation implantation. Endoscopic management of gastroparesis most commonly involves intrapyloric botulinum toxin injection; however, there exists a variety of endoscopic approaches on the horizon that have the potential to radically shift standard of care. Endoscopic management of gastroparesis seeks to treat delayed gastric emptying with a less invasive approach compared to the surgical approach. This review will serve to highlight such innovative and potentially transformative, endoscopic interventions available to gastroenterologists in the management of gastroparesis.

Keywords: Botulinum, Gastrojejunostomy, Transpyloric, Pyloromyotomy, Gastric stimulator, Gastric pacemaker, Stenting
Core tip: Although a majority of gastroparesis patients respond to medical treatment, patients with refractory symptoms pose a therapeutic challenge and are often referred for surgical management. Endoscopic management of gastroparesis seeks to treat delayed gastric emptying with a less invasive approach compared to the surgical approach. Endoscopic treatment of gastroparesis most commonly involves intrapyloric botulinum toxin injection; however, there exists a variety of endoscopic approaches on the horizon that have the potential to radically shift the standard of care for refractory patients.


INTRODUCTION
Gastric emptying is a highly regulated, carefully choreographed process that demands a harmony of synchronized impulses working together as an impetus for which food can be delivered distally down the gastrointestinal tract. These propulsive forces are generated by proximal fundic tone, the interstitial cells of Cajal, distal antral contractions, and relaxation of the pyloric sphincter to create a scripted peristalsis[1]. Gastroparesis, or delayed gastric emptying, is characterized by physiologic disturbances in antral hypomotility, increased gastric outlet resistance, and pyloric dysfunction without evidence of obstruction[2,3]. Patients typically present with dyspepsia-like symptoms including early satiety, postprandial fullness, bloating, nausea, vomiting, and abdominal pain[2,4-6]. The most common etiologies of gastroparesis are idiopathic, diabetic, or post-surgical[2,7].

The epidemiology of gastroparesis is not well known though a small population-based study showed a prevalence in men and women of 9.6 and 37.8 per 100000 persons and an age-adjusted incidence of 2.4 and 9.8 per 100000 person-years, respectively[8]. Gastric-emptying scintigraphy is the gold standard for the diagnosis of gastroparesis and consensus recommendations for the procedure involve 99-m technetium sulfur-colloid labeled low fat, egg-white meal with imaging at 0, 1, 2, and 4 h[9]. The diagnosis of delayed gastric emptying is confirmed if there is > 90% gastric retention at 1 h, > 60% at 2 h, > 10% at 4 h[9,10]. Small, frequent meals along with medical therapy including prokinetic agents, such as dopaminergic (D2) antagonists - metoclopramide and domperidone, or motilin-analogue - erythromycin, are the first line of treatment.

The majority of data regarding the efficacy of conventional prokinetic agents for the treatment of gastroparesis is outdated[11-15]. It has been approximately 30 years since the first randomized controlled trials of the conventional prokinetic agents, metoclopramide, domperidone, and erythromycin, have been published, and despite this, they are still first-line agents for the treatment of gastroparesis[16]. Metoclopramide has been the most extensively studied and has been associated with less improvement in gastric emptying when compared to erythromycin[15]. A meta-analysis assessing benefits of four different drugs in 514 patients in 36 clinical trials reported the macrolide antibiotic erythromycin as the most potent stimulant of gastric emptying, while erythromycin and the dopamine receptor antagonist domperidone (not available in the United States) are best at reducing symptoms of gastroparesis[17]. Currently, several novel pharmacotherapies such as ghrelin receptor agonists (TZP-101, TZP-102, RM-131), mitemcinal, prucalopride, velusetrag, levosulpiride are in development, though their clinical efficacy and safety remains to be established[16,18,19]. While it is generally accepted that a significant percentage of patients require additional therapy beyond prokinetic agents, no clear data exists to determine the percentage of patients who fail medical management.

Patients with symptoms refractory to medical therapy pose a therapeutic dilemma. Patients are often referred for surgical treatment including a variety of potential procedures not limited to gastrostomy, jejunostomy, pyloromyotomy, pyloroplasty, and gastrectomy to improve gastric emptying. Poor and sometimes unpredictable response, in addition to the morbidity and mortality of surgical interventions, has led to the emergence of endoscopic therapies in management of gastroparesis (Table ​(Table1).1). While frequently under-utilized, endoscopic treatment strategies are at the cusp of altering traditional standard of care with exciting new developments that have the potential to radically shift the preferred management of refractory gastroparesis.


BOTULINUM TOXIN INJECTION
Endoscopic intrapyloric botulinum toxin injection (IPBI) is the most studied and perhaps the most commonly employed endoscopic treatment for those suffering from refractory gastroparesis, though this therapy still remains highly controversial. Botulinum toxin is a potent inhibitor of neuromuscular transmission used more commonly for the treatment of spasm in gastrointestinal sphincters. Botulinum toxin injection into the lower esophageal sphincter (LES), with or without endoscopic ultrasound (EUS)-guidance, is an established safe and effective therapy for management of achalasia in high-risk surgical patients. Low dose injection of botulinum toxin in the pylorus muscle decreases contractility secondary to decreased acetylcholine release by irreversibly binding to cholinergic receptors and directly affects muscle tone at higher doses[20]. The toxin also reduces substance P immuno-reactivity and disrupts pyloric myoelectric activity[21,22].

The procedure involves endoscopic access to the patient’s pylorus with injection typically in a radial pattern at or within 2 cm of the pylorus, with a total dose of 100 to 200 units[23]. There is an alternative hypothesis that antroduodenal or pyloroduodenal manometry may be helpful to evaluate the baseline pylorus muscle tone to determine the best site for IPBI to predict response; however, this warrants further investigation[24]. The usual duration of benefit from IPBI ranges from 1 to 5 mo at which time worsening symptoms can be re-treated with repeated injections[23,25]. It is important to note however, that the effect of IPBI may not be limited simply to the pyloric muscle as there have been rare reports of gastric and intestinal absorption leading to peripheral neuromuscular blockade[26]. Despite this, the procedure is typically well tolerated and safe. There are a multitude of open-label studies in adults with gastroparesis (regardless of cause - idiopathic, diabetic, and post-surgical) reporting an improvement in symptoms and gastric emptying after endoscopic IPBI[25,27-31]. The largest observational study including 63 patients by Bromer et al[25] documented a 43% response rate to botulinum toxin treatment lasting a mean of approximately 5 mo.

While observational data suggests that botulinum toxin injections reduce symptoms and accelerate gastric emptying in both idiopathic and diabetic gastroparesis, 2 independent, double-blinded, randomized controlled studies have shown little to no improvement in gastric emptying and no symptomatic improvement compared with placebo[32]. Friedenberg et al[33], using a randomized, double-blind, placebo-controlled trial, explored whether botulinum toxin improves symptoms to a significantly greater extent than placebo. In this study, 32 patients were randomized to botulinum toxin or placebo with 1-mo follow-up post endoscopic procedure measuring gastric retention at 2 and 4 h and symptoms based upon 2 validated scoring systems - the Gastroparesis Cardinal Symptom Index (GCSI) and the Gastroparesis Visual Analog Scale (GVAS). While endoscopic botulinum toxin injection did improve gastric emptying rates, the benefit was not superior to placebo at 1 mo (67% vs 64% at 2 h, P = 0.56 and 29% vs 28% at 4 h, P = 0.86, for IPBI vs placebo respectively). Additionally, there was no significant difference or improvement of symptoms between IPBI compared to the placebo (GCSI - 34.4 vs 36.4, P = 0.21; GVAS - 603 vs 584, P = 0.68, respectively). Another randomized-controlled crossover study including 23 patients, predominantly with idiopathic gastroparesis, also reported similar results, with no significant benefit of endoscopic injection of botulinum toxin over placebo in improving either symptoms or rate of gastric emptying[34].

This discrepancy between open-label and randomized controlled studies may be related to dose of toxin injected and patient population selected. In a retrospective cohort study of 179 patients by Coleski et al[23], patients treated with 200 units achieved a greater improvement in gastroparetic symptoms 1 to 4 mo post intervention compared to those treated with 100 units (76.7% vs 54.2%, P = 0.02). On multivariate analysis female gender, age < 50 years, and a non-diabetic or post-surgical etiology of gastroparesis were found to be associated with a significant response to therapy in this study. While the use of botulinum toxin remains highly controversial, the American Gastroenterological Association (AGA) currently does not recommend the use of endoscopic IPBI for patients with gastroparesis[35]. However, given the small sample size of existing studies with conflicting data, there is an eminent need for larger randomized trials in the future before a definitive decision or treatment guidelines can be concluded.

Source: http://www.gastrotraining.com/gi-surgery/bariatric-surgery/roux-en-y-gastric-bypass/roux-en-y-gastric-bypass



ENDOSCOPIC GASTRIC STIMULATOR IMPLANTATION
In 2000, gastric electrical stimulation (GES) was approved by the United States Food and Drug Administration (FDA) as a humanitarian device exemption in patients with refractory symptoms of diabetic or idiopathic gastroparesis[36]. Often referred to as a gastric pacer, GES uses an implantable device consisting of a pulse generator that allows for electrical stimulation at a variety of frequencies. Permanent GES for gastroparesis, typically 6 cm x 5.5 cm x 1 cm, requires a lengthy surgical implantation under general anesthesia. Several case series and small randomized controlled trials, the most important being the Worldwide Anti-Vomiting Electrical Stimulation Study (WAVESS), have shown clinical benefit from GES[37-43]. A subsequent meta-analysis by Chu et al[44] in 2012 confirmed significant improvement in symptom severity and gastric emptying times, though many of the analyzed studies were low quality observational studies lacking control groups. A more recent study by McCallum et al[40] also demonstrated improvement in weekly vomiting frequency amongst all patients with idiopathic gastroparesis with a median reduction of 61.2%. The National Institute of Health and Care Excellence issued guidelines in 2014 that stated current evidence is adequate to support the use of GES[45].

As of 2012, surgery was the only means available to implant the GES device. Although endoscopic placement of temporary gastric stimulators has been proven as a concept and is often used to determine whether a patient will respond to GES before undergoing a permanent implant surgery, the lack of a permanent endoscopic solution and the reliance on future surgery for symptomatic improvement has limited further endoscopic utilization at present[46,47]. However, Deb et al[48] has designed 5 innovative endoscopic gastric implantation techniques and developed a novel, wirelessly powered miniature gastrostimulator. While this early model was conducted in pig studies with no human data or patient trials, the study provides an important prototype for other dysmotility treatment paradigms and provides exciting new options that may translate in the future to less invasive endoscopic placement in gastroparetic patients. This miniature wireless GES device for endoscopic implantation can be easily inserted into the stomach through an over-tube with 2 GES electrodes endoscopically attached to the gastric mucosa and secured with endoclips[49]. Electro-gastrogram recordings have demonstrated that gastric slow waves become more regular with constant amplitudes when stomach tissues are stimulated, in comparison with no stimulation. The frequency-to-amplitude ratio also changes significantly with stimulation[49].

The miniature gastrostimulator and its attachment techniques have the potential to fundamentally shift the approach to refractory gastroparesis and provide a means for endoscopic implantation of gastric stimulator. Although further studies are required to prove the efficacy of such device, if shown to be effective, the possibility of FDA approval given a similar precedent set by GES would provide a clear indication for endoscopic management. The endoscopic gastric implantation device and technique may decrease the need for surgical implantation of GES and revolutionize the preferred management of refractory gastroparesis.


TRANSPYLORIC STENTING
A novel approach recently described by Clarke et al[50] at Johns Hopkins involves the use of through-the-scope transpyloric stent placement as a treatment for gastroparesis. In this small case series (n = 3), double-layered, fully-covered Niti-S self-expandable metallic stents (TaeWoong Medical, Seoul, South Korea) were used to successfully improve symptoms of gastroparesis. The procedure entails the placement of a self-expandable stent across the pyloric channel, deployed under endoscopic guidance without fluoroscopy. The stent is then fully deployed in the transpyloric position with its proximal end in the gastric antrum. Case 1 involved a 23-year-old woman with diabetic gastroparesis; case 2, a 15-year-old boy with chronic nausea and vomiting with markedly abnormal gastric emptying study; and case 3, a 45-year-old man with idiopathic gastroparesis. In all 3 cases, patient symptoms markedly improved or became asymptomatic at 115 d, 122 d, and 174 d follow-up respectively. While this includes only a case series of 3 patients, the stark improvement and lasting results at follow-up after the procedure suggest that transpyloric stent placement improves symptoms associated with impaired gastric emptying[50].

A major concern with transpyloric stenting is stent migration leading to recurrence of symptoms. Several stent securing methods such as endoscopic clips [through-the-scope clip (TTSC) and over-the-scope clip (OTSC)] and endoscopic suturing (ES) have been described to reduce stent migration. Despite the numerous options available, the question remains which stent securing method is superior. In a small case series by Saxena et al[51], transpyloric stent placement and fixation was performed in patients with refractory gastropariesis. The stent was anchored to the antral mucosa with either no device, TTSC, OTSC, or ES. A total of 17 patients underwent 28 transpyloric stent placements with 100% success rate regardless of method. Stent migration occurred as expected in 100% of those with no device; however stent migration was significantly lower in the ES vs TTSC group (16.7% vs 100%, P = 0.02). Stent migration occurred more frequently in the OTSC placement group as compared to the ES group (52.9% vs 16.7%, P = 0.075). With this data, albeit limited due to the number of the patients studied, there is evidence for concern regarding stent migration with transpyloric stent placement; however, it appears this can be minimized with OTSC and endoscopic suturing.

Currently, future studies are required to truly ascertain the long-term durability, utility, and preferred method for transpyloric stenting and fixation. Until that time, transpyloric stenting will remain a limited option for endoscopists in the management of patients with refractory gastroparesis.


ENDOSCOPIC PYLOROMYOTOMY
Rao et al[52] demonstrated that phasic motor activity in the antrum and duodenum can be stimulated by fundic balloon distention. While there are no such studies to determine the effect of pyloric channel distention on the interstitial cells of Cajal in the stomach or gastric emptying, endoscopic pyloromyotomy and manipulation of the pylorus may improve gastroparesis refractory to medical management. With this notion of distention or disruption of the pylorus to improve gastroparetic symptoms, Khashab et al[53] demonstrated the feasibility and efficacy of this approach with a case report of the first human gastric peroral endoscopic myotomy (G-POEM) in a patient with severe refractory gastroparesis. The procedure was well tolerated with vast improvement in gastroparetic symptoms noted at 12-wk follow-up.

This technique is similar in principle to the submucosal dissection and myotomy performed for the treatment of achalasia[54]. Techniques through a submuscoal tunnel were first described in animal models by Pasricha et al[55] in 2007. Endoscopy is performed and involves myotomy of the inner circular and oblique muscle bundles 2-5 cm proximal to the pylorus on the anterior wall of the stomach, preserving the longitudinal muscle layers with larger vessels in the submucosa coagulated. This is then followed by endoscopic pyloromyotomy by dissecting the pylorus until deeper layers become evident with full separation of the pyloric ring[54,56].

In another study by Shlomovitz et al[56], endoscopic pyloromyotomy was performed in 7 female patients with early follow-up suggesting promising symptomatic improvement in 6 of the 7 and normal gastric emptying studies at 4 h noted in 4 of the 5 patients. One patient that did not respond subsequently underwent laproscopic pyloroplasty. Complications included gastrointestinal bleeding in one patient 2 wk after the procedure and pneumonia. Despite these complications, this endoluminal pyloromyotomy technique could provide an incision-less, less invasive alternative with similar functional outcome as compared to standard laparoscopic pyloroplasty[56]. While the small number of cases certainly limits the ability to determine the true impact of this procedure in the management of gastroparesis, with more frequent use, increasing technical experience, and more data, endoscopic pyloromyotomy has exciting potential to be at the forefront in the endoscopic management of gastroparesis.


ENDOSCOPIC DECOMPRESSION OR BYPASS
Enteral nutrition and feeding is sometimes required for more severe symptoms and can be seen in up to 30% of grade 3 gastroparesis[57,58]. Direct percutaneous endoscopic jejunostomy (DPEJ) is a push enteroscopy technique that was first described by Shike et al[59], and offers another approach to provide direct postpyloric enteral nutritional support. Percutaneous endoscopic jejunostomy (PEJ) is a safe and effective means to palliate malnutrition in patients with severe gastroparesis[60,61]. Maple et al[62] demonstrated, in the largest cohort study to date, clinical outcomes with DPEJ and included 307 attempts at PEJ placement with a success rate of 68%. While this study included multiple indications for DPEJ placement, gastroparesis was a substantial proportion (n = 61 or 21%). A case series by Toussaint et al[63], showed a PEJ technical success rate of 78.6% with no immediate complications reported; however, this was based upon a small sample size of 14 patients total. Based on these data, PEJ should be considered in the algorithm of enteral access for nutritional support before jejunostomy is considered.

The main limitation of DPEJ is technical difficulty as the jejunum is narrow, making it more difficult to advance a needle directly into the lumen[64]. This difficulty can be alleviated with balloon-assisted enteroscopy (BAE)[65]. Aktas et al[66] reported the first prospective study in which single-balloon enteroscopy (SBE)-assisted DPEJ was successful in 11 of the 12 procedures (92%). In this prospective case study, SBE was shown to facilitate the identification of an ideal DPEJ insertion site for the placement of a direct percutaneous jejunal feeding tube. While again this study is limited in size, the results were similar to previous small case series using double-balloon enteroscopy (DBE)-assisted DPEJ placement[65,67].


ALTERNATIVE TO SURGICAL GASTROJEJUNOSTOMY
While surgical gastrojejunostomy is a potential treatment option for patients with gastroparesis, the procedure is associated with substantial morbidity and mortality when patients are in less than ideal clinical condition[68-71]. Fritscher-Ravens et al[72,73] and Binmoeller et al[74] first described EUS-guided gastrojejunostomy in pigs by using a compression button and lumen-apposing metal stent, respectively. These studies were built upon the success of previous studies - notably Cope et al[75] creating the first transluminal anastamosis using self-expanding metal stents (SEMS) and Chopita et al[76] reporting the first clinical trial using fully covered version of the flared stent. While the Fritscher-Ravens et al[72,73] and Binmoeller et al[74] studies were performed as possible alternatives to surgical bypass for the palliation of malignant gastric outlet obstruction, more benign conditions such as gastroparesis may potentially benefit from this transluminal therapy.

An additional study performed by Itoi et al[77], developed a new enteric tube that allowed for the entrapment of fluid between the double balloons without the need to use tissue-opposing devices such as tilt tags. This maintains distention of the small bowel between the double balloons at the initial FNA needle puncture site. Although simply a pilot study, all stents, with exception of one stent, were successfully deployed without complication. All animals showed normal eating behavior without signs of infection at 1-mo follow-up post procedure. Endoscopic gastric imaging showed patent stents in all pigs. While this study lacks power, the initial findings are impressive. The development of a EUS-guided gastrojejunostomy appears to be promising as a minimally invasive treatment.

Although surgical gastrojejunostomy has been shown to improve gastroparetic symptoms, EUS-guided gastrojejunostomy warrants further investigation owing to unknown long-term stent safety and patency issues[74]. Ideally, the stent can be removed after an interval of time, leaving a permanent fistula tract. However, studies are needed to determine the necessary pressure gradient and initial gastrojejunostomy tract diameter in order to maintain long-term fistula patency after stent removal. The minute amount of data available to date, while optimistic and potentially transformative, requires repeat analysis and trials with human study before implementation into the gastroenterologist’s everyday arsenal. However, given the technical success of studies above, the future of endoscopic gastrojejunostomy using EUS-guided lumen-apposing metal stents is bright with the potential to diminish the need for invasive surgeries and improve symptoms of gastroparesis refractory to medical management.


CONCLUSION
In summary, there is a wealth of potential endoscopic approaches that may one day be at the disposal of endoscopists. While many of these procedures and pioneering approaches have the potential to be ground-breaking and radically transform the standard management algorithm of refractory gastroparesis, all of them require more studies to validate, corroborate, and substantiate early optimistic data. The opportunities for less invasive endoscopic treatment of gastroparesis are abundant and inspiring. From further studies to evaluate the true effectiveness of IPBI to the potential for EUS-guided lumen-apposing metal stents for gastrojejunostomy, the role of endoscopic therapies in management of gastroparesis is likely to expand in near future."

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462724/

Handling Holidays with A Chronic Illness

I know this time of year is really rough for all of us. As someone with GP, I cannot eat like normal people do on thanksgiving. I plan to cook for my family and friends, but I was wondering how to deal with the fact that I can't eat like normal people and what to do about it. I did some research and found some articles that might help the chronically ill deal with this issue. Additionally, I found some information for family members who always tell us to eat something or try to force us to eat when we are unable to. I hope this will help everyone a bit.

Image taken from: http://images.wisegeek.com/sad-dark-hair-woman.jpg


WebMD (http://www.webmd.com/balance/features/chronic-illness-holidays) gives us a wonderful source for how to deal with the holidays and loved ones as well. The key seems to be planning ahead and communicating your illness and requirements in advance to family and loved ones:

"Rosalind Joffe, MEd, once hosted a Thanksgiving dinner for 22 people at her house. She planned it months in advance. She hired someone to clean. She created a menu and delegated various dishes to guests. A friend came over the day before the holiday to set the table. Relatives were assigned jobs to serve dinner and clean up afterwards. Joffe has the planning sense of Martha Stewart. She also has multiple sclerosis (MS) and ulcerative colitis.

While it was challenging to host Thanksgiving, she says she'd have felt worse if she hadn't. "The key was advance planning," she tells WebMD. "What I've learned is if I ask for help in advance, even with my own family, people don't feel put upon. They feel they're a part of the event."

Joffe is among the many people living with chronic illness -- defined as lasting more than three months, being persistent or recurrent, having a significant health impact, and typically being incurable. So, with Christmas and Hanukkah at hand, times when everyone is supposed to participate and feel cheerful, what are some strategies for coping?



Do Holidays Make Chronic Illnesses Worse?

There's always the temptation to abandon healthful living routines around the holidays. Eating too much, not getting enough exercise, staying up late, worrying about family members getting along -- all these things can make you feel worse. But do they negatively affect your health?

Joffe, who coaches people with chronic illness in the Boston area to thrive in the workplace, says it depends on the disease. "With diabetes, heart conditions, or epilepsy, for example, you must take care of yourself or the disease gets worse. With autoimmune diseases, such as MS, fibromyalgia, or lupus, your symptoms will get worse but not the disease itself."

What about the holiday blues? Do the holidays really bring on episodes of depression? Michael Thase, MD, during a WebMD Live Event, said geography could play a role. "As people living in the northern hemisphere, we seem to be somewhat more prone to development of depression in the fall and winter months. The fact that this period of risk coincides with our holidays is kind of like a bad coincidence. For example, I'm not sure that I've encountered any writing about the holiday blues in New Zealand, Australia, or South Africa."



Speak Up

"Holidays act like a lightning rod where all the physical and social concerns around chronic illness get really highlighted," says Patricia Fennell, MSW, LCSW-R. She explains that the demands and expectations around holidays can "out" people whose conditions were hardly noticeable. During the year, they spend so much of their energy working and handling the daily chores of living that they have little time left for socializing. Come the holidays, they're expected to show up and contribute.

"Many chronic illnesses, such as diabetes, depression, arthritis, fibromyalgia, etc., are 'invisible,'" Fennell says. "People go to work or volunteer or shuttle kids to school. Most of the time, they don't look sick. When illness flares up, their pain is invisible. Or they have bone-numbing fatigue, so bad that they can't take a shower and go to the store in the same day. There's a cultural misperception that says you're not sick unless you look sick. They need to make their illness visible by talking about it."

Fennell, who is president and CEO of Albany Health Management, Inc., in Albany, N.Y., coaches patients on how to negotiate needs. "People don't know how to ask for what they need. They'll stay home from a holiday party because they can't stand that long. We need a new social etiquette for people with chronic illness."



Party Strategies: Ask for What You Need in Advance

Fennell describes a typical holiday scenario. "You're invited to Aunt Jane's. Let her know that you'll do your best to attend her party, but that if your illness flares up, you may have to bow out. Ask her how much lead time she needs. She'll say, 'Anything's fine.' Tell her you'll call her 48 hours in advance to let her know. Uncle Bob will still be annoyed if you don't come, but if you predict that you're unpredictable, people will generally handle it better."

She advises stating your needs in behavioral rather than general terms. "Don't just tell Aunt Jane you'll have to leave early. Tell her you've been feeling fatigued and can stay only two or three hours. Also tell her that standing tires you out, and ask her to have a seat for you. Putting it in behavioral terms makes it easier for Aunt Jane to conceptualize and to accommodate."

Many hosts and restaurants have become accustomed to considering various dietary needs for guests who have heart disease or diabetes or another condition that requires a restricted diet. "They should be offering options for people," Fennell tells WebMD. "If you don't know what's being served, carry a large handbag with snacks and water, or offer to bring a dish that can be shared with others."

When you're the host, whatever you do don't wait till the last minute to ask for help, says Joffe. "You may not get the help you need. And if people do help, they might resent it. Become an expert at planning. Asking in advance allows people to help gracefully."



Managing the Handicap Parking Space

Shopping and gift giving present special challenges, not the least of which is managing the mall. If your illness is invisible, the challenge can start when you get out of your car. Some less-than-jolly shopper who parked way out in left field will let you know that you have no business parking in a handicap space. Try to think of a humorous retort, like that of a cancer patient who plucks off her wig and smiles.

Joffe advises not letting presents and errands get out of control. "Many people with chronic illness aren't in the best financial situation but don't have the energy to shop for bargains. Plan in advance. Take a day off work so you can shop yet avoid the weekend crowds. The key is what matters most to you. Is it going into your bank account? Would a simple note do? Don't go into lock-step motion."



Ways to Relieve Holiday Stress

An article in Arthritis Today offers three tips for managing holiday stress:

Daily rest and relaxation. Don't get stuck in a never-ending to-do list. Do a crossword puzzle or take a walk or a nap. The mental and physical break will rejuvenate you.

Prioritize. Decide how much shopping, cooking, or partying you can do and stick to it. Ask for help.

Volunteer. Take toys to the Marine Toys-for-Tots Foundation, take food to homebound seniors through Meals on Wheels, or provide goods and services for Hurricane Katrina victims. It will boost your spirit and remind you what the holidays are about.

Patch Adams, MD, the real doctor whose life was the basis of the Robin Williams' movie, would agree that volunteering is good for you. He heads the Gesundheit! Institute in Arlington, Va. It's the umbrella organization for his work to raise funds for a variety of projects, including the building of a free hospital in rural West Virginia.

He tells WebMD, "My best advice for someone with chronic illness coping with the holidays is to work out with their families not to give presents, but instead to give money to local families who are poor, and consume half of what they normally consume. Make it about the spirit of giving."

The numbers of people with chronic illness are growing, and that's not necessarily a bad thing, says Fennell. "People are living today with heart disease and cancers that were once considered terminal illnesses, not chronic illnesses."

The growing numbers also mean you're not alone. Next time you go to a holiday party, look around. Some of those healthy looking people may have chronic illnesses, too."

Image Source: On Image.









This part is for your loved ones, family and friends and dealing with your loved ones, family, and friends. It's to help them understand what we go through and what they can do for the chronically ill. This source does talk about making food for your chronically ill loved one, but with GP, that can be a challenge. We have a very strict diet but you can modify this article to match up with your loved one's dietary restrictions.




According to Kevin M.D. (http://www.kevinmd.com/blog/2011/11/living-chronic-illness-holiday-season.html):

"In the U.S., we’re getting ready to celebrate Thanksgiving. Soon, people around the world will turn their attention to the holiday season. Chronic health problems can take a toll on relationships any time of the year. Most people have to experience unrelenting pain or illness themselves before they understand how debilitating it is, physically and mentally. Loved-ones (by whom I mean family and close friends) may be in some form of denial about what’s happened to you, or they may be scared and worried about the future. Bottom line, suffering from a chronic condition can be an ongoing crisis—for you and for those you’re close to.

That crisis can come to a head during the holidays when people’s expectations of one another are high and when stress levels for everyone are likely to be off the charts for any number of reasons—health, financial, relationship issues. If you’re like me, during the rest of the year, you carefully limit interactions with others in order to manage your symptoms; on a typical day, your most complex decision may be to choose between showering and shopping! But when the holidays arrive, you’re suddenly thrust into the middle of a lively and chaotic social scene where you’re expected to participate in a range of activities, often for days in a row. A bit of advance warning to loved-ones can go a long way toward minimizing stress levels over unrealistic expectations.

I know that this piece won’t apply to everyone. One of the heartbreaking consequences of living with chronic pain and illness is that some people are unable to be with loved-ones at all during the holidays, either because people are too disabled by their pain or illness to be able to gather with others, or because family and close friends having drifted out of their lives. I know the pain of that isolation; I’ll be writing about it in my next piece.

For those of you who are able to gather with others, the holidays can be a recipe for double disaster—the increase in activity exacerbates your physical symptoms, while coping with sadness, frustration, and maybe even guilt about your physical limitations gives rise to emotional pain. No wonder many people with health problems dread the approaching holidays.

If you’re one of the many people with chronic health problems who don’t look sick, the initiative is with you to make your condition visible. Here are some suggestions for helping loved-ones understand what your life is like and for giving them a heads-up on what to expect from you during the holidays.



Share information with them from the Internet or from books

Often the best way to educate loved-ones about chronic pain and illness is to use a neutral source because it takes the emotional impact out of the communication. A quick web search will yield a host of organizations devoted to every conceivable medical problem. Print out select pages or forward a few links to family and close friends. Alternatively, if you have a book about your condition, photocopy the pages that cover what you’d like them to know about you. In your accompanying note, keep it “light”—you could joke that “there won’t be a test.” But also make it clear that this favor you’re asking is important to you.



Write a letter

Many years ago, two friends of mine were in couples therapy. They weren’t able to speak to each other about their marital problems without one of them shutting down emotionally and the other reacting by shouting recriminations. Their therapist told them to write letters to each other expressing their feelings and their concerns about the marriage. It turned out to be a major first step in healing their relationship.

If you decide to write a letter, be sure it’s not accusatory. In composing it, use the word “I” more than the word “you.” Without complaining, express how difficult it’s been for you to adjust to this unexpected change in your life and how you wish you could be as active as you once were during the holidays.

You could briefly describe what your day-to-day life is like, including how unpredictable your condition is which means that you can’t know for sure how you’ll feel on the day of the actual gathering no matter how much you rest in advance. (This is the hardest concept for most loved-ones to comprehend—that we can spend weeks before a big event in full “rest mode,” but still feel very sick when the day arrives.)

I would end by telling them what to expect from you during the holidays—that you may have to skip some events, that you may have to excuse yourself right after eating to go lie down, that you may have to come late and leave early. In my experience, spelling out my limitations ahead of time is helpful not just to others, but to me, because I find it much easier to exercise the self-discipline it takes to excuse myself from a room full of people if I know that at least some of them are already expecting it.

P.S. It will be tempting to send an email, and if you have a lot of people you want to communicate with, it may be the most feasible way to reach everyone. But one thing’s for sure: people will read a handwritten letter, antiquated document that it’s become!




Find that ONE ally and enlist his or her help

If you have just one close friend or family member who understands what you’re going through, enlist his or her help in explaining your condition and your limitations. Before the holidays start, you could ask your ally to talk to loved-ones on your behalf or to be present when you talk to them. Ask your ally to be supportive if you have to excuse yourself in the middle of a gathering, or even to let you know if you’re wilting (as we call it in my household). It’s so helpful for me to be “prompted” by my ally because, when I start to overdo things, adrenaline kicks in which fools me into thinking I’m doing fine. But using adrenaline to get by just sets me up for a bad crash later on.

Your ally may be a close friend or family member who’s just waiting for you to enlist his or her help. Think long and hard before you decide there’s no such person in your life.




In the end, you may have to recognize that some loved-ones may never accept your limitations

Some family and close friends may refuse to accept that you’re disabled by pain or illness. I know this from personal experience and it hurts. Try to recognize that this inability is about them, not you. Don’t let their doubt make you doubt yourself. Your medical condition may trigger their own fears about illness and mortality, or they may be so caught up in problems in their own lives that they’re not able to see their way clear to empathize with you.

Just as you can’t force people to love you, you can’t force people to accept you. But getting angry at them just exacerbates your own symptoms. That’s why it’s important to protect yourself from allowing their lack of understanding to continually upset you. Think of it as protecting yourself from another chronic condition: chronic anger.

The physical suffering that accompanies chronic pain and illness is hard enough to endure without adding emotional suffering to it. When I feel let down family or close friends, the first thing I do is acknowledge how much it hurts. Then I reflect on the many possible reasons for their behavior. Finally, I work on genuinely wishing them well. These three steps immediately lessen my emotional suffering.

As you experiment with these suggestions, treat yourself kindly. Don’t blame yourself if one of them doesn’t work out. Instead, give yourself credit for having had the courage to try! My heartfelt wish is that your loved-ones come to understand and accept your limitations, but that if they don’t, you’ll be able to accept them as they are without bitterness."

According to EmpoHER (http://www.empowher.com/wellness/content/helping-chronically-ill-over-holidays):

"One of the unique problems that comes with chronic illness is that ... it lasts so long.

Some chronically ill people are fortunate to have a solid support network of family and friends. For others, things are very different.

If there were people interested in helping, while they may have been dedicated and compassionate at first, the long haul proved to be too long. The sprint they could run was too short for the marathon of chronic illness.

Many of us have outlasted our helping companions and carry on down the bleak road alone.

Do you know someone who is alone this holiday season? Maybe you can't commit great blocks of time or resources to their care and comfort.

But if you can spend a little time, and maybe even a little money, and you just need some suggestions, you're headed in the right direction.

You don't have to look for big things to make a difference for many who are chronically ill.

Things that you may take for granted, that seem like no big deal in your own life can be things that have stumped the chronically ill with a wall of impossibility for a long time.

Ever made lunch? Fixing something for your friend will not only brighten their day with your caring actions, it will also take care of a practical problem.

Some people who are chronically ill must spend most of their energy putting a meal together, needing to recuperate for the rest of the day afterward. Others just end up not eating.

Washing laundry, sticking it in the dryer and doing some folding are simple chores. Having a friend come over to go through these paces can bring a sense of order to a home that may be short on that quality.

Clean clothes, especially when they've been hung up and placed in drawers, bespeak affection and closeness for someone who may not feel that very often. Not to mention, you will save them their little energy quota for the day for other things.

When you have to run to the store, perhaps you could call or stop by to see if your friend needs anything as well. One trip, two sets of errands accomplished. Less stress and pressure on your friend, and you go home feeling like you've made a difference.

This time of year, snow can be a going concern in many areas of the country. Chances are your friend can't lift a shovel let alone clean a walk or driveway.

Whether we're talking about a shovel, a snowblower, or a snow plow -- whether you do the job yourself or pay someone else to do it -- removing their snow can also remove the burden of being faced with an insurmountable task.

And if you'd like some hot chocolate afterwards, you could come in and spend time with your friend ... and make hot chocolate for both of you.

The possibilities, really, are endless if you want to help someone who is chronically ill. The holes in their abilities and resources are often vast and widespread.

Do it for the holiday season, or just do it for a friend whose daily existence may be tougher than you can begin to fathom."

Dealing with isolation can be a huge problem for gastroparesis patient and also the chronically ill. Many of us are too sick to go out anywhere or even be around food. In that case, the source below will give you some tips on what to do when you're isolated during the holidays.






According to You Don't Look Sick (http://www.butyoudontlooksick.com/articles/guest-writers/tip-handling-isolation-that-comes-from-chronic-illness/):

"The title is ominous, I know. But for so many of us that suffer from chronic illnesses, it’s an all too true reality. I must preface this by saying that not all people who suffer with a chronic illness experience this. However, the subtleties of it grow as time passes and one is confronted with the reality of it, be it large or small, at some point in their lives.

It may be as small as the awareness of the decrease of invitations by friends due to our physical limitations. For some, that awareness grows to a more glaring, in your face, epiphany that friends that were always there before suddenly wish no part in your life…excuses a plenty. It’s not even relegated to just friends. Family roles play a big part of isolation experiences for the chronically ill. Those closest to us are often the ones to fall into one of two categories. Faithfully standing by no matter what or those that turn a blind-eye and deaf-ear to our honest answer to their question, “How are you?”

It’s important for the chronically ill to have a plan to handle times of feeling isolated. This is true whether you’re feeling isolated now or think it’s a possibility for your future. The realities of life are handled better if we understand the possibilities and have a plan on ways in which to deal with such times. Let’s talk about some ways to handle isolation times in your life.

We’re blessed to live in a time of the information super highway. Social network sites make it much easier to remain in our homes, if needed, yet still be interactive on a day to day basis. Whether it be local friends and family or online acquaintances, it’s there for our using and can keep us connected to the real world. Some suggestions might be the bydls.com on facebook or the butyoudontlooksick.com message boards

Not only do we have a multitude of e-social activities to participate in, we have a vast array of research at our fingertips. We can be pro-active in our medical care simply by spending time doing a bit of our own educating.

Can we say real life support groups? If ever there was a source of interaction for the chronically ill and isolated, it’s support groups. Some of the most wonderful people you’d ever want to meet are in a support group and can truly say, “Been there, done that!” Or, they say nothing at all but have golden ears to listen with.

Blogging is one of my favorites. It’s like your online diary. I like to be able to express myself, and even my feelings of isolation, in words. Many blog sites can be set to private so that no one, other than those you want, can read them. Many of the aforementioned support group sites offer their own blog space just for you. You never know when someone will read your blog and be totally blown away by the knowledge that someone else is going through exactly what you are.

So, you see, isolation doesn’t have to take over. Yes, there are times where quiet reflection is needed but no longer do we have to draw back into a dark place in our minds where loneliness rules. Like the old yellow pages ad said, “Let your fingers do the walking!” Get out there via the internet and keep in touch with friends and family. Find new friends that can relate to what you’re going through and can offer hope, encouragement and support that you may not have otherwise. It’s a good choice to make and certainly a good way to handle isolation for the chronically ill."

I really hope this article will help you deal with the holiday stresses. I know all holidays are centered around food, and it's hard to ignore. But, remember, even though the holidays are tough, YOU ARE TOUGHER!

Going on a Cruise with GP

Well, for the past week, my husband surprised me with a cruise to the Carribean and Bahamas for our ten year wedding anniversary. I have to admit, I was a bit apprehensive. I had been really ill with a gastroparesis attack or flare for a while now. However, I wanted to get away. I needed to rest and the ocean sounded wonderful. Swimming and a hot tub sounded wonderful. I really wanted to make the best of it and crossed my fingers that I would have some good days. I didn't want to disappoint my husband or make him feel bad. It was really sweet of him to take me on a cruise that I've never done before, plus go to islands I wouldn't have thought to visit. So, I packed and was feeling excited. I had hope and that's important.

I was scared that I would be sick on the cruise in an RV sized bathroom:

The corner of the room in the far right was the restroom.


I have to admit, though, the cruise was relaxing. I think the ocean helped a lot, believe it or not. One of the few things that doesn't make me sick is the ocean. I don't get sea sick. However, the cafe we ate (or me, barely ate at) was buffet style with a lot of people. It made me sad to look at all of the things I couldn't have. Also, people seemed to bathe in perfume or cologne. It made me gag a few times in the elevator going up to the cafe. When I got there, all I could think was:

I did make the mistake of trying to eat and be normal. I went horseback riding in the ocean, which was amazing. Then, I noticed my belly swelling up like I was nine months pregnant. I felt so self conscious and unbelievably fat. I'm heavy already but not usually that heavy, which is weird to me because I almost never eat. The people at the horse farm weighed me in front of everyone because they said the horses couldn't take someone over two hundred and thirty pounds! I've never weighed anything like that, ever. I just felt sad and depressed but riding in the ocean with the horse made it better.

I was a poster child for this picture.



When I do eat, I get cramps (really bad ones), and then I start vomiting. The last two days of the trip, I spent in and out of the bathroom and was so amazingly ill. I started crying at one point because I felt like I couldn't go on. My throat and belly hurt so much, even my knees hurt from bending over to get sick.

I got to celebrate my tenth anniversary without a flare. Thankfully, it waited until the next day. I had so much fun on my cruise. I got to sit on the balcony of my room, listen to the ocean and read. If you're thinking of going on a cruise, I'd recommend it. I have a blog article about traveling with GP that may help you if you think you wouldn't be able to travel:

Previous blog article: http://www.emilysstomach.com/2013/07/information-about-gastroparesis-and.html

I was scared but everything turned out all right. I say if you want to travel, you should go for it. Don't let your GP stop you. I didn't.

Another Sleepless Night & Another New Symptom

I am so exhausted.

I can't sleep and all I can do is to curl up in a ball and whimper. The pain hurts. It's one huge spasm after another and the vomiting makes the pain worse. I'm pretty sure I pulled a muscle in my back vomiting this last time.

My fraternity's local alumni association had a holiday get together today. My husband is deeply involved in this organization and he's been here to support me, so I wanted to be there today to support him. The holiday get together was at a local soul food restaurant. Now, just the smell or image of food had me gagging this week, but I was determined that I was going to get through this lunch. I felt like I was marching to an execution and praying I didn't get sick at the restaurant. I took all of my medicine before I got into the car which includes Bentyl, Levsin, Zofran, Phenergan, Zanaflex, and my vitamins I've started taking. I added a multivitamin to the mix along with Vitamin B, because that was recommended to help my new symptoms of confusion. I've also been trying to add more potassium to my "diet."

I was quite proud of myself. I didn't get sick in the car and when I walked into the restaurant, the smell didn't knock me out like I thought it was going to. I managed to make myself eat a teaspoonful of dressing, two teaspoonsful of lima beans, and a few bites of banana pudding. After that, I was full. Also, a new symptom developed. Right after I ate, my belly started to swell. It looked like I was pregnant or that I had a balloon under my shirt. It was very uncomfortable and full of cramps. I actually had to change my pants later because they were too tight after I ate.

I managed to last the entire lunch without vomiting several times. I had to leave and get some air towards the end of lunch because the smells were making me extremely nauseated.

After getting into the car, the nausea became worse. Nothing helped. Not looking outside, not counting trees, not trying to relax, nothing. My stomach felt like someone was banging on it with a hammer. It was this intense, throbbing, sharp pain. It continued to do this until I got home. The spasms started happening and then I started vomiting. At least I had something in my stomach to vomit up, so it wasn't just stomach acid. My throat is still rather swollen from previous vomiting and it probably sounds and looks like I have strep throat.

I was up all last night vomiting and now I've been up all tonight vomiting. One of my friends said something, probably not meaning to be offensive but it came out that way, and I finally just broke down and cried. I sat there and cried for a good two hours. My wonderful husband, who lost his father this week, sat there and held me while I cried. He didn't ask what was wrong, he just stroked my hair. I felt so guilty because I feel like I should be comforting him, you know?

After crying, I vomited again. At this point, I left my bedroom to come upstairs to watch TV. I don't want to wake my husband up and my stomach isn't going to let me sleep anytime soon.

I managed to read all of, Gastroparesis: My Personal Journey and realized that I have the same symptoms. This isn't in my head. I can't tell you how many doctors have told me that the sickness is in my head and nothing more. I've had several friends remark about how strong I am but I don't feel strong. Then, I read something like this book and what this woman went through and it motivates me to be an advocate for myself.

I'm going to stick with facts and what I do know. I know that I vomit 6 to 8 times a day. I know that I'm dehydrated. I know that I'm still technically overweight but I've lost about 25 pounds since I was diagnosed. I've dropped a bra size and pants size. I can put two photos of me side by side from this year and last year and you can see that my face has thinned out considerably. I know that I look sick and that my skin is a weird pasty color. I know that if I make myself eat, even small and frequent meals (liquids), I will vomit.

I know that I can't leave the house without a a bucket of some sort to vomit in. I know that I have a year of college left and I'm not sure how I'm going to go to labs. I know my GI doctor doesn't know what to do for me at this point so he's referring me to the Mayo clinic. I know that I have mental confusion, depression, and my stomach becomes really swollen if I do manage to eat something. It doesn't matter what I eat, it all comes up. Liquids, solids, gluten free, gluten, etc. I've tried all of the different diets. I know that I'm scared (and I have a suspicion that I have an autoimmune disease at the heart of this problem - but I don't know what I've been tested for).

I also know that I am determined. I know that other GP fighters suffer worse than I do. I know I have loving family and friends who support me, even when I post six million times a day on Facebook to keep myself distracted. I appreciate all of the help my husband has given me and his support. Without him, I'm not sure I could do this. I know that I've found a wonderful support group online that has helped me so much with venting and answering most of my gastroparesis questions. Also, it makes me feel better to know that I'm not the only one.

I know that I'm going to keep fighting.

Updates on GP Management

I just downloaded a book that I hope will help that I found through the Gastroparesis community on Facebook. It's called, "Living Well with Gastroparesis" by Crystal Saltrelli. It has 75 recipes that should be easier for me to digest. I'm also going to try and keep a food journal to see what works and what doesn't.

What makes me happy about this book is that the author's story sounds strangely like mine. She went to the doctor and was diagnosed with Gastroparesis without hearing that word before, ever. Then, she went to the Motility Specialist who wrote her off because the Specialist felt that she wasn't a severe case, even though she was hospitalized over and over (much like me) for nausea, vomiting, and severe pain. It's just scary how similar my situation is to this woman.

The recommendation is to eat six small meals a day but that's challenging for me. I'm usually full after one small meal for several days, IF it stays down. I went to the doctor yesterday, dehydrated, and my blood pressure was back up to 140/110 because I was in pain and spent the last three days vomiting. I vomit, on average, about 6 to 8 times a day. Mostly, it's just green stomach acid because there's nothing left to come up at this point. Liquids won't even stay down.

I hope this book will help me learn to manage this condition. She says that the gastric pacemaker worked wonders for her and helped her to digest food easier. This was mentioned to me once by my GI doctor, but I haven't heard much else about it.

I can't live this way anymore. I can't leave my house without a bucket. I barely eat. I've lost 20 pounds. The doctors aren't sure what to do. The Motility Specialist doesn't want to see me until I need a feeding tube but I'd prefer not to have it come to that, you know?

I'm lethargic and tired. My friends don't want to hang around me, because let's face it, I can't go anywhere with my head shoved into a bucket. I just feel isolated and alone sometimes - and it hurts because no one understands this condition. My husband has been my rock and has been really supportive. But, I miss going out, even little things like to the movies or camping. The smell of food makes me really ill. I have to hide away from it when people are cooking downstairs.

I went to my regular doctor yesterday. He gave me Phenergan and Bentyl, which have helped in the past but it's hard for me to keep pills down. My stomach is bloated and swollen with severe pain. My skin is clammy because I have a fever. I managed to catch some kind of stomach virus ... and let me tell you, that plus gastroparesis makes me feel like I'm dying. The doctor wanted to put in an IV to hydrate me, but I was so dehydrated that he couldn't find a vein...not even in my FOOT! He said I should go to the emergency room but I just couldn't bring myself to go. I didn't want to wait 6 to 8 hours to be given pain and nausea medicine to be sent home just to have it all repeat over again. I want help managing the problem - not masking the symptoms.

Tuesday, I have a surgery scheduled for the Spinal Cord Electrical Stimulator (back surgery to control the nerve damage). This should help the nerves in my knee from misfiring me to tell me my knee is in severe pain. I'm hoping this will cut the vomiting in half as vomiting is also my pain response. That way, I can tell what is coming from my stomach and my stomach alone. Also, this will help me to walk again without making me feel like I've broken a bone in my knee. Walking is supposed to help digestion.

I will start the food journal tomorrow. I'm going to browse through these recipes to see if I can find anything worth making. I might have to make my husband do it because anything involving cooking or being near food makes me ill. I don't know if it's just in my head or what, but I can't deal with strong smells right now. I've been resting and trying not to push myself. I've been trying to drink gatorade, apple juice, and eat yogurt. Soft things that won't be too harsh on my stomach. I ate rice last night which was a bad mistake because now I have horrible gastric cramping. Before long, I just might have to buy some baby food and go from there.

What's even worse is that I've felt too sick to do anything. It's like everything I used to care about isn't even a priority at the moment because I am just so ill. I hate feeling that way. I miss my friends. I miss my family. It's even hard for me to play a video game because the games make me motion sick.

I just wish doctors wouldn't write me off because I'm not in need of a feeding tube yet. You think that they'd try to keep me from getting one, right? I'm just not sure what to do at this point. I don't want to be hospitalized for another 8 days but at the same time, I'm too weak to even take a shower to wash my hair.

I Forgot to Eat

I managed to forget to eat today. Since I was up all last night vomiting, I took a long nap today. When I woke up, I realized I missed my dosage of medication. Now, it feels like my stomach has been sucker punched (bad cramps) with an overlay of burning.

I'm trying to eat a baked potato in hopes that it will stay down. I need something on my stomach to vomit because vomiting stomach acid hurts. Also, I'm a bit worried about my teeth. What effect will all of this vomiting have on my teeth?

I wish I could control this pain. The pain goes overlooked by my doctor because the vomiting takes priority. I'm also scared that it's nerve pain and if it is, there's nothing I can really do about it. Nerve pain is hard to treat.