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Abdominal CT Scan

An abdominal CT is a good way to more extensively look for a blockage or obstruction. Typically, it is performed with contrast for best results, but can be done without if necessary.

Preparation:

Usually, patients are advised to not eat within 4-6 hours before the test. Often patients are required to drink oral contrast immediately before the procedure in order to improve images and accentuate any potential problems. This may involve the need for arrival at the radiology center about an hour in advance in order to allow time to drink the barium and coat the intestines. Sometimes physicians do not require this, particularly if the patient is symptomatic or has a hard time eating or drinking.

Before the test:

In addition to oral contrast, the patient may be given an IV for IV contrast. Allergic reactions to IV dye are not uncommon and include shortness of breath, rashes, etc. Often premedication with Benadryl is necessary to prevent a reaction. Normal feelings from the contrast include flushing, sensation of heat, and desire to empty the bladder. These pass within a few seconds.

During the test:

The patient is instructed to lie very still on a table on his/her back, usually with his/her arms and hands resting above the head. The table is advanced so that it enters a tube (scanner), but not closed like an MRI. He/she is instructed to hold his/her breath for a few seconds at a time as images are taken as the scanner circulates around the body. Several images are taken, depending on the number of organs being tested.

After the test:

If there are no emergent complications, the patient is allowed to resume normal activity. If oral contrast was used, he/she may experience white stool for a few days, diarrhea, constipation, and a feeling of fullness.

Results:

Positive results may indicate a small bowel obstruction or blockage, tumor, infection, or a number of other illnesses. Typically, results are available rather quickly after the procedure on a preliminary basis.

Alternative Treatment for Nausea

One of the many difficult challenges of living with digestive tract paralysis can be learning to manage nausea. While not every patient experiences this symptom, those that do know how quickly it can turn a good day upside down. It is common for doctors to prescribe medications as well as recommend over the counter products for temporary relief. While it’s important to listen to your physician, it’s also good to educate yourself on the variety of alternative options available.

  1. Tummy Toolkit

Think of this as the digestive tract paralysis first aid kit. No matter where you find yourself, having the necessary tools with you at all times provides comfort and some form of relief. Nausea can be soothed through many of our senses including taste, smell, touch, and hearing. The following includes helpful examples of each one.

Taste – Ginger and Hot Teas
Ginger chews may help calm the stomach as well as indigestion and convenient to have with you at all times. Otherwise, when you can, sip on ginger tea and experiment with fresh ginger in recipes such as carrot ginger soup. If ginger tea is too spicy for you, try using fennel. Crush a tablespoon of seeds and steep in hot water for 10 minutes. Strain and sip as necessary for nausea.

Smell –Aromatherapy
Our sense of smell begins working at the very first stage of digestion, immediately releasing digestive juices in the mouth, stomach, and small intestine. Taking a few deep breaths of a specific or prepared blend of essential oils can provide quick relief when it comes to both nausea and discomfort. Popular oils include peppermint, spearmint, ginger, basil, and chamomile.  For more information on essential oils, go to https://organicdailypost.com/ultimate-guide-to-essential-oils/.

Prepared blends available:
Quease Ease Aromatic Inhaler can be found at www.soothingscents.com
Digest Ease and Microflora Support found at http://www.snowlotus.org/

How to use

– Directly inhale from the bottle or place a few drops in tissue and inhale.

– Massage around abdominal area.

– Mix with water and add to a spray bottle for home and car.

– Add 5-10 drops into a bathtub with warm water.

Feel – Acupuncture and acupressure wrist band
If available in your area, give acupuncture a try. It has been proven to help with many ailments, nausea being one of them.

To find a certified local practitioner go to http://www.nccaom.org/fap

Wrist bands – Commonly used on cruises and boats for seasickness, this band gently stimulates a point on the wrist known to decrease and/or prevent nausea. Target now sells them on their website, just enter “acupressure wrist band” in the search box. If you don’t own one, you can also learn to massage the point yourself.

For detailed instructions, you can go to http://www.wikihow.com/Stop-Nausea-With-Acupressure

Hear – Music therapy and guided imagery
Both have been shown to reduce nausea and anxiety. If it’s an option, keep a playlist on your phone, music player, or CD with tunes that make you feel calm and relaxed. A good place to start is an audio by Dr. Andrew Weil, Sound Body, Sound Mind.

  1. Breathing Techniques

With nausea or any pain for that matter, it’s easy to freeze up, focus on the pain, and forget what the body naturally wants to do, which is to breathe. If not practicing already, make it a point to make breathing a habit whenever that unpleasant feeling begins to take over.

Alternate Nostril Breathing
Alternative nostril breathing can help to calm the mind and release tension and fatigue.

Diaphragmatic (Abdominal) Breathing
Abdominal breathing can help with relaxation and prevent symptoms associated with stress.

The most important thing you can do for yourself and for digestive tract paralysis is to have proper nutrition. This can often be difficult for patients, especially when nausea plays into your daily life. However, each one can feed on each other, creating a vicious cycle from either, 1) not eating well therefore increasing nausea or, 2) increased nausea lessening the amount of proper food intake. When food sits in the stomach too long there is a higher chance of experiencing symptoms such as nausea and vomiting. For many, prevention of symptoms begins by eating small, balanced meals throughout the day and always including some form of protein. For example, six mini-meals a day as opposed to three average-sized meals.

You may find it helpful to work with a practitioner who specializes in both nutrition and gastroparesis. See our section on Registered Dietitians.

Botox Injection

Botox, the same treatment used for treating wrinkles, is often effective in treating gastroparesis as well. It is a less invasive procedure operating on the same idea as a pyloroplasty. Botox is given locally so side effects are not common.

Preparation:
Botox is injected during an endoscopic procedure. The patient must remain NPO after midnight the night before the procedure.

Before the procedure:
The patient will be instructed to arrive at the hospital approximately 30-60 minutes before the actual injection is scheduled. He/she will be given an IV, placed on a heart monitor, and receive oxygen throughout the procedure. Once ready, the patient will be taken from the holding room to a procedure room where he/she will be instructed to lay on his/her left side and then given IV sedation.

During the procedure:
While the patient is sedated, the physician will advance a scope through the esophagus, stomach, and to the pyloric sphincter. Botox is injected into the pyloric sphincter in an effort to relax that muscle, enabling food to empty from the stomach more easily. It takes approximately 15-30 minutes.

After the procedure:
The patient will return to a holding area to recover from the IV sedation. Once he/she is able to sit up and tolerate a small amount of fluid, the patient will be discharged into the care of a family member. Driving is restricted for 24 hours.

The effects of the Botox may be felt immediately or may take some time to begin working. Complications from the procedure include nausea and vomiting from sedatives. Although rare, some report bleeding, perforation of the esophagus, fever, or severe vomiting.

Botox injections are not a permanent solution and usually last no more than 6 months. Repeat injections do not always produce the same results.

CIP Symptoms

Symptoms of CIP include:

Abdominal Distention/ Bloating

Abdominal Obstructions/Blockages

Early Satiety

Nausea

Vomiting

Heartburn

Abdominal Pain

Constipation

Weight Loss

Chest Pain/Esophageal Spasms (may feel like a heart attack)

Decreased or no Bowel Sounds

Inability to pass gas

Poor Appetite

Malabsorption

Vitamin Deficiencies

Fatigue

Diarrhea (less common)

Poor Growth and/or Development (children)

It is not unusual for those with CIP to have other portions of the GI tract also affected; this may include Dysmotility in the esophagus and/or stomach (Gastroparesis) and, for some, includes problems with bladder emptying as well.

CIP Treatment Options

There is no specific treatment for individuals with CIP.  Treatment is directed toward the specific symptoms that are apparent in each individual, and to support adequate nutritional needs.  The treatment plan may require the efforts of multiple of specialists.  Each patient is different and will require an individual plan.  Given the differences in each patient, the treatment plan that works for one may not work for another.

The specific therapeutic procedures and interventions for individuals with CIP will vary, depending upon numerous factors including the specific symptoms present, the site and extent of the affected portion of the GI tract, an individual’s age and overall health, tolerance of certain medications or procedures, personal preference and other factors.

Treatment options for individuals with CIP are complex and varied and often prove difficult. The specific treatment plan may be highly individualized and can include can dietary adjustments, total parenteral nutrition (TPN), enteral feeding, certain medications and surgery. 

Individuals with CIP are encouraged to eat five to six small meals a day rather than three large ones and to follow a low-fat, low-fiber diet. Such a diet may emphasize liquids and soft foods. Fatty foods are believed to delay gastric emptying. High fiber foods are thought to be associated with abdominal bloating and discomfort.

Some physicians may recommend avoiding lactose because of the high incidence of lactose intolerance in the general population. Affected individuals may also be encouraged to follow a low-residue diet, which limits foods that leave undigested parts in the GI tract (these undigested parts normally become part of stool). A low-residue diet is similar, but generally more restrictive than a low fiber diet.

Affected individuals may also need to take daily multivitamins and nutritional supplements, which are beneficial for individuals who experience nutritional deficiencies and/or malnourishment. 

Colostomy

A colostomy is an opening that connects the colon to the surface of the abdomen. This is called a stoma and it provides a new path for waste material and gas to leave the body. A colostomy can be either permanent or temporary.

How is a colostomy performed?

A colostomy results from a surgical procedure performed under general anesthesia. During the surgery, a healthy colon is brought through an opening in the abdominal wall and stitched to your skin. Unlike the anus, the opening (stoma) has no sphincter muscle, so you cannot control the exit of waste. You will need to wear a pouch (called an ostomy collecting device) to collect the waste flow.

What are the complications of a colostomy?

In some cases, skin irritation can result from stool that leaks under the pouch. A hernia can develop around a colostomy. The bowel may become narrow or it may prolapse, which means it gets longer. Proper fitting of an ostomy pouch can help prevent skin irritation.

http://my.clevelandclinic.org/disorders/colorectal_cancer/hic_colostomy.aspx
http://www.webmd.com/colorectal-cancer/guide/living-colostomy

Endoscopy

An upper endoscopy (EGD) is performed by a physician and is often used to determine if a patient has an obstruction or tumor-causing delayed gastric emptying rather than a neuromuscular problem such as gastroparesis. It can also identify other problems such as ulcers, gastritis, and thrush.

Preparation:

The patient will be instructed to not eat or drink anything after midnight the night before the test. Typically, crucial morning medications are allowed to be taken with a small sip of water.

Before the test:

It is usually necessary for the patient to arrive at the hospital 30 minutes to an hour before the test. The medical staff will review medical records, allergies, and monitor blood pressure and temperature. The patient will be placed on a heart monitor and given an IV in preparation for IV sedation. Once taken to the procedures room, the patient will then be given medication to numb the throat. Sedation medications are started, and the patient is instructed to lay on his/her left side.

During the test:

After the patient is sedated, the doctor guides a scope down his/her esophagus and into the stomach. The physician will see live images on a computer screen as the scope is advanced. Pictures are also taken to review later. Biopsies are usually taken to rule out other problems. This portion of the test typically lasts 15-30 minutes.

After the test:

The patient is returned to a recovery area to be monitored until he/she is alert and able to drink sips of water or juice. Driving is restricted for 24 hours, so the patient must be accompanied by a friend or family member. It is recommended that a soft diet be followed for the remainder of the day. Common side effects include nausea, bloating, fatigue, and gas. Bleeding, fever, or pain are uncommon but should be reported immediately.

Results:

In the case of gastroparesis, the results may show severe gastritis (inflammation of the lining of the stomach) or no peristalsis (contractions) of the stomach. It may also show undigested food from the previous day indicating delayed emptying. The EGD is also indicative of gastroesophageal reflux disease (GERD). Biopsies taken during the procedure are evaluated to determine if there is another underlying cause of the disease.

 

Enterra Therapy

Enterra® Therapy, also known as the gastric electrical stimulator (GES), is an implantable device used to help stimulate the smooth muscles of the stomach in patients with refractory gastroparesis who have failed all drug treatment options. It may be placed either laparoscopically or through a laparotomy depending on the need of the patient.

Enterra was approved by the FDA in 2000 for use as a humanitarian device in cases of idiopathic or diabetic Gastroparesis. This means it is only available in certain hospitals that have been reviewed and approved to perform the procedure. Because it is humanitarian in nature, it is often not approved by insurance companies or the approval process can be complicated. Medtronic reps are available to assist in getting patients approved for the procedure.

While the device is not a cure for GP, it does improve nausea and vomiting symptoms in many patients. It does NOT cause the stomach to contract and will not aid digestion. The settings on the device are increased or decreased based on symptom control and patient tolerance. Settings can be adjusted at the physician’s office by external remote control. Whether the improvement is gradual or immediate depends on the patient.

To learn more about Gastroparesis and treatment options, please visit the Medtronic website.

 

Feeding Tube Care

What should the site look like?

Feeding tube sites (G/J and J tube) tend to drain a lot.  As long as the drainage is clear or tan, moderate in amount, and not particularly smelly, it is probably normal.  Don’t be surprised if you find crusted drainage around the site.  At times, drainage may contain a small amount of blood.  If the drainage smells putrid or unusual or is oddly colored, copious, or extremely bloody should be evaluated by your doctor.

As the new site heals, it forms a stable tract or tunnel between the skin and the stomach or intestine where the tube is placed.  A stable tract is important, as it decreases pain, promotes healing, and prevents leakage and granulation of tissue to some degree.  The best way to create this stable tract is to keep the new feeding tube secure

How should I clean the tube site?

  • Tube sites can usually be clean with just water.  The area can be cleaned gently with Q-Tips, a washcloth, or gauze or during showers with just regular soap and water.
  • After cleaning the area, it should be dried thoroughly with a clean towel.  The area can also be left open so it can dry completely.

What is granulation tissue?

Granulation tissue is a common problem with tubes and is typically caused by irritation or moisture at the stoma site.  Granulation tissue is pink or red and tends to be soft, fleshy, and blobby.  A slight tannish, odorless discharge may also occur.   It tends to bleed easily and can be extremely painful.

Ideas for treatment (please check with your physician before attempting any of these methods):

  • For mild granulation tissue, try dabbing aloe vera juice on the site or rubbing a piece from an aloe vera plant around the site.
  • Miracle Mist Plus spray or gel also helps treat mild granulation tissue.
  • Triple paste, made by mixing an over-the-counter antibiotic cream, an over-the-counter hydrocortisone cream, and an over-the-counter antifungal, works well as a preventative.
  • Calmoseptine lotion may help in mild cases.
  • Cholestyramine ointment is highly effective and is available by prescription through compounding pharmacies.
  • Triamcinolone steroid cream is available by prescription and treats mild to severe granulation tissue.  Treatment can be started with low-strength and increased to the high-strength formulation if no response.
  • Silver nitrate sticks literally “burn” the granulation tissue off.  These are only available by prescription.  Make sure to cover the healthy skin around the site with barrier cream or Vaseline to prevent it from being “burned.”  Note that silver nitrate will get rid of granulation tissue but will not prevent it from coming back. 
  • In rare cases, surgical removal of the tissue is required. 

Can medications go through an NJ, G/J, or J tube?

Yes, almost all medications can be put through these tubes.  Most medications are absorbed into the small intestine and can be given through any type of J tube.

The exception is medication that is in bead form or tablets that do not dissolve smoothly.  These are likely to clog the tube, which is particularly a problem with the narrower size of NJ and G/J tubes.

In general, it is best to give medications in liquid or suspension form.  Tablets should be crushed well or allowed to dissolve completely before administering.

What type of feeds may be used for J feeding?

Because the jejunum is a smaller diameter than the stomach and lacks an expandable area or fundus, continuous or slow feeds using a pump are mandatory in J feeding.  Some people may need to be on feeds 24 hours a day, while others may be able to feed at a faster rate for 16-20 hours per day.  Medications may also be given as small boluses. 

http://www.oley.org/tubetalks.html

G-POEM - Gastric Peroral Endoscopic Myotomy

Dr. Khashab and his colleagues pioneered the G-POEM at John’s Hopkins. The POEM was initially performed on patients suffering from Achalasia and provided encouraging results.  The POEM was then trialed on individuals with Gastroparesis.  Instead of opening the sphincter between the esophagus and stomach, the surgeon will open the pyloric valve. Through endoscopic measures, the inner layer of the pyloric valve is cut, also known as a myotomy.

Preparation: 

You will be on a liquid diet for 48 hours prior to the procedure. This is to ensure that nothing is in the stomach or esophagus on the day of the procedure. Twelve hours before the G-POEM you will be asked to take nothing by mouth.

Before the procedure: 

You will be asked to report 2 hours before the procedure.
An IV will be inserted to provide fluids, anesthesia, and antibiotics.

During the procedure: 

You will be asleep.
An arterial line will be placed to monitor your blood pressure.
The doctor will insert an endoscope and inspect the pyloric valve.
After the inspection, an incision in the stomach will be made.  The doctor will then cut the inner lining of the pyloric valve. This is termed myotomy.
After this, the incision will be closed with standard endoscopic clips.

After the procedure: 

You will be taken to recovery as the IV sedation wears off.
Once recovered, you will be admitted for observation.
You still will not be able to eat or drink.
The next morning you will have an upper GI with barium.
If there appears to be no complications, you will be discharged and able to go home.
Although there are no long-term results, as this procedure is fairly new, the short-term results are very exciting and hopeful.  Literature supports that G-POEM improves both symptoms and gastric emptying in postinfectious, postsurgical, and idiopathic refractory gastroparesis (Mekaroonkamol et al., 2016).

References
Johns Hopkins Medicine (n.d). Gastroenterology and hepatology: Peroral endoscopic myotomy (POEM). Retrieved from here.

Mekaroonkamol, P., Dacha, S., Keilin, S. D., Willingham, F. F., Cai, Q., Li, L. Y., & Xu, Y. (2016). Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes. Neurogastroenterology and Motility, 28(8), 1272-1277.

Gadgets & Tips

Feeding tube pads

Button pads can help absorb leakage from the stoma and tube and help to reduce irritation and inflammation around and under the tube.

Some people choose to leave their tube site open to the air, however, others find that a dressing or pad is needed for comfort and/or to keep control of significant leakage.  One approach is to take a piece of IV split gauze (with an opening for a tube or line) and place it under the tube or button, taping the two sides together to keep it in place.  The gauze soaks up the moisture, but the area still stays wet and can lead to the growth of granulation tissue.

When choosing a dressing for your tube site, pick one that pulls moisture away from your skin, and allows air to flow around the tube.

One great option is reusable homemade pads, typically made of two or three layers for absorption.  These are inexpensive and practical, and many options can be found on the Internet.

Backpacks

Backpacks are essential for feeding on the go.  Your choices include specialized backpacks made for feeding pumps or any small backpack with some slight modifications.

Some use regular backpacks that they have customized with hooks and/or Velcro strips. Others will buy hydration packs used for hiking and biking, remove the bladder, and fit their feed set inside. These packs have elastic openings for the feed line to come out on either side, allowing the bags to remain tightly zipped and secure in crowded areas, as well as camouflaging the feed set, which many patients find desirous in a work environment or social setting.

Securing your line

An easy solution to keep your line from getting snagged is to pick up a few of the cell phone belt clips that can be snapped into the back of phone cases. Attach the clip to the bottom half of a backpack strap or the top of your belt, thread the line through it, and push the slack back into the bag. This will keep your feeding line snug to your body and less likely to be snagged by others around you.

Another option is to apply a tape tab near the end of the feed line and secure it to your shirt or waistband with a safety pin. Long tubes can be secured the same way. Simply place a tab of paper tape (or a similar tape that won’t leave behind sticky residue) near the end of your tube (but before the port). Use a safety pin to attach the tab to the inside of your shirt or the waistband, and you will keep your tube from moving around, but allow the port to be free for feeding or irrigation.

Miscellaneous

The Lopez Valve connects to your tube (J, G, G/J, NJ, etc.) and then the other end of it connects to the feed set. The valve has a wheel on it which functions as a stopcock. It allows a patient to flush or take medicines without disconnecting from the feed set. The wheel is turned, flow is stopped from the feed set, and a syringe can be inserted into the small adapter it has for liquids. After flushing or administering meds, the wheel is returned to its place and feeds begin again. This helps minimize the risk of infection to the patient, particularly if they are traveling and needing to flush or take medicine in non-sterile, public environments.

Another useful device is the AMT clamp. Although most patients will meticulously hook up their feed bags and make sure the connectors are tightly fitted to their feed port, disconnections happen, and they can be messy! The AMT clamp has 2 ends. One end secures around the patient’s port, and the other end secures around the feed set connector. It is just long enough to hold the two ends together so that the feed connector cannot separate from the port. This is especially important at night when a patient might unwittingly roll over the connector and dislodge it.

For patients with a G, NG, or G/J tube who experience severe gas bloating and pain, a useful product is the Farrell Valve Bag. It can be hooked up to a patient even while they are feeding, and it will allow for continuous gastric decompression. It does not need to be used only during feeds but can be left connected to the tube.

For more resources, check out:

Gastroparesis Diet Guidelines

STEP 1. Gatorade and Bouillon

DIET: Patients with severe nausea and vomiting should sip small volumes of salty liquids such as Gatorade or bouillon in order to avoid dehydration. Any liquid to be ingested should have some caloric content. A multiple vitamin supplement should be prescribed.

GOAL: To ingest 1,000 to 1,500 cc per day in multiple servings, e.g., twelve 4 oz. servings over the course of 12-14 hours.

AVOID: Citrus drinks of all kinds and highly sweetened drinks.

STEP 2. Soups 

DIET: The diet may be advanced to include a variety of soups with noodles or rice and crackers. Peanut butter, cheese, and crackers may be tolerated in small amounts. Caramels or other chewy confections may be tried. These foods should be given in at least six divided meals per day. A multivitamin should be prescribed.

GOAL: To ingest approximately 1,500 calories per day. Patients who can accomplish this will avoid dehydration and will hopefully ingest enough calories to maintain their weight.

AVOID: Creamy, milk-based liquids. The fat in the meal will delay the emptying of the stomach.

STEP 3. Starches, chicken, and fish

DIET: Starches such as noodles, pasta, potatoes, and rice are easily mixed and emptied by the stomach. Thus, soups, mashed potatoes or baked potatoes, pasta dishes, rice, and baked chicken breast and fish are usually well-tolerated sources of carbohydrates and protein. These solids should also be ingested in six small meals per day. A one-a-day vitamin should be prescribed.

 

GOAL: To find a diet of common foods that the patient finds interesting, satisfying, and that evoke minimal nausea/vomiting symptoms.

 

AVOID: Fatty foods that delay gastric emptying and red meats and fresh vegetables that require considerable digestion. Avoid pulpy fibrous foods that promote the formation of bezoars.

IMPORTANT: Please remember that the diet is trial and error and what works for one may not work for another. This is simply a basic guideline.

*Diet created by Dr. Ken Koch, M.D., Director of GI at Wake Forest University Baptist Medical Center

Other diet suggestions can be found at:

www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/patient-education/Gastroparesis2010-10.pdf

www.arizonadigestivehealth.com/gastroparesis-diet/

www.nutrition411.com/education-materials/allergies-intolerances-and-special-diets/item/471-gastroparesis-guidelines-tips-and-sample-meal-plan

Gastroparesis Tips

Tips offered by other gastroparesis patients:

 – Sit up after eating

 – Walk after eating

 – Belly massage

 – Chew small bites of ginger

 – Acupuncture

 – Nausea wrist bands

 – Try to eat foods that are GP-friendly.  Stay away from fried and greasy foods

 – Chew gum

 – Do mild exercises such as walking, pilates, or yoga

 – Use heating pads on your stomach to help ease the pain

 – Eat small meals – 5 to 6 small meals per day

GP Causes

There are many different causes of gastroparesis, although the connection between disorders is not completely apparent in many scenarios.

Diabetes is the most common cause.

Abdominal surgery, such as nissen fundoplication, gastric bypass surgery, gallbladder removal. Surgery may injure the vagus nerve which is responsible for causing the stomach muscles to contract, pushing food out of the stomach. If the vagus nerve is damaged, it becomes paralyzed and is unable to perform this function. In some instances, post-surgical gastroparesis is temporary, and the stomach returns to normal after healing.

Neurological disorders

Neuromuscular disorders

Mitochondrial diseases affect at least three major organs and can explain why a person may have a number of seemingly unrelated problems Rheumatoid or immune deficiency disorders (scleroderma, lupus)

Idiopathic (no known cause)- common suspect in idiopathic cases is viral. If caused by a virus, the GP may reverse itself over time.

Eating disorders (Anorexia Nervosa, Bulimia). Gastroparesis often improves once food intake and eating schedules normalize. This is often due to the stomach muscle-weakening because of lack of use. A blockage caused by ulcers and/or tumors could imitate gastroparesis.

Temporary gastroparesis can be caused by certain medications such as narcotics and some IBS drugs including levsin and bentyl, calcium channel blockers, and certain antidepressants

Endocrine disorders

Cancer and/or radiation treatment and some types of chemotherapy

Viruses can cause gastroparesis.  In many cases, post-viral gastroparesis will resolve within 6 months to 2 years.

The U.S. National Library of Medicine (http://www.nlm.nih.gov/) Johns Hopkins (www.hopkins-gi.org), and Mayo Clinic (www.mayoclinic.com) are a few great sources of reference for Gastroparesis.

Gastroparesis Testing

There are a variety of tests that doctors may use to diagnose GP. Although the standard test is the gastric emptying scan, it’s important to have other tests performed to verify the diagnosis, look for potential causes, and rule out additional conditions.

GP testing can often be difficult as most tests require the ingestion of food or contrast in order to be performed. Many tests require sedation. However, they are all important in getting to the final diagnosis and figuring out the best course of treatment.

Recently, newer tests have become available which are geared towards an accurate diagnosis without the need for ingestion of large amounts of contrast or food. However, these tests are not diagnostic on their own and additional testing may still be necessary.

Most GP tests require a patient to be NPO (nothing by mouth) after midnight the night before the test, or to do some sort of prep. Medications are usually stopped to ensure the greatest accuracy of results. In most cases, testing can be done on an outpatient basis.

As of April 6, 2015, the FDA has approved a new test for diagnosing gastroparesis, the Gastric Emptying Breath Test (GEBT).

Intestinal Biopsy

Once the diagnosis of chronic intestinal pseudo-obstruction (CIP) is established, the underlying etiology should be determined.  It is recommended that all patients undergo laboratory testing to identify secondary causes of CIP.

A full-thickness biopsy is rarely needed and should be considered in patients with severe dysmotility of unknown etiology who undergo surgery, in patients with poor outcomes after surgery, or in patients with a permanent catheter for enteral or parenteral nutrition.

Preparation:

You cannot eat or drink anything for at least 4 hours before the test and should inform the doctor if you regularly take anticoagulants or non-steroidal anti-inflammatory drugs (such as aspirin, ibuprofen, or naproxen). These medications must be discontinued for some time before the procedure to reduce the risk of bleeding complications.

About the test:

The procedure used to obtain the biopsy depends on which section of the intestine is being tested.

It can be obtained by endoscopy if the doctor is getting the biopsy from the first part of the intestine (the duodenum).  After giving you a sedative and other medication, the doctor inserts the tube into your mouth, down your throat, and into your esophagus—the long, hollow passageway that connects your throat to your stomach.  When the tube reaches your stomach, the doctor uses the camera to find the duodenum—the entryway into your small intestine—and inserts the tube there.  Your doctor inserts a tiny surgical instrument through the tube and into your small intestine. Your doctor will then take tissue samples from two or three areas of your small intestine.

However, most biopsies for CIP are obtained from the jejunum (the second portion of the intestine) and are usually obtained during placement of a J-tube or during another surgery that involves the small intestines (i.e., ostomy) while you are under anesthesia.  This area is extremely difficult to access by endoscopy or colonoscopy.

Results:

Biopsy specimens are sent to a pathology laboratory and examined under a microscope for changes that indicate a bacterial or parasitic infection or another abnormality.  The findings from a full-thickness intestinal biopsy may help differentiate between myopathic, neuropathic, or other disorders as the cause of CIP.

This test usually results in a definitive diagnosis. Results may take a few days to weeks to come back.  Your doctor will recommend an appropriate course of treatment, depending on the specific results.

Source:  The Johns Hopkins Consumer Guide to Medical Tests.  http://www.healthcommunities.com/digestive-system-tests/small-bowel-biopsy-small-intestine.shtml

Medication for CIP

Unfortunately, medications to treat chronic intestinal pseudo-obstruction are limited.  A variety of different medications may be used to treat individuals with CIP. Medications can help to control symptoms and to avoid complications. Antibiotics may be prescribed to treat bacterial infections and can help relieve diarrhea and bloating. Drugs that are effective against nausea and vomiting (antiemetics) may also be used.

Prokinetics are a class of drugs that are often prescribed to individuals with CIP in order to improve gastrointestinal motility. Examples of prokinetic drugs are Erythromycin, Metoclopramide (Reglan), Domperidone, Octreotide, Tegaserod, Lubiprostone, and Prucalopride.

Low-dose tri-cyclic antidepressants and gabapentin have been used to treat chronic pain and to help with nausea.

Pain medications such as narcotics should be avoided because they can further deteriorate digestive function by decreasing motility.

Antiemetics are used to treat nausea and vomiting.  Examples include Promethazine (Phenergan), Prochlorperazine (Compazine), Ativan, and Ondansetron (Zofran)

Ativan – used to control nausea, but causes extreme drowsiness

Bethanechol – Used to stimulate esophageal motility

Marinol– Approved Marijuana drug that is given to chemo patients or others with severe nausea

PPI– Used for GERD as well as healing esophagus due to acid.  Examples: Prevacid, Prilosec, Nexium, Protonix, Aciphex

Periactin (cyproheptadine)- Used to relax pyloric sphincter and as an appetite stimulant

Be sure to discuss your medication plan with your physician, especially what side effects to expect.  What works for one patient may not work for another, and it may take some trial and error to find the right combination that works for you.

NG/NJ Tubes

The first type of temporary tube is an NJ-tube (nasojejunal). The tube is generally placed by an interventional radiologist under a continuous x-ray procedure known as fluoroscopy. The tube is placed into the nose and advanced down through the esophagus and stomach. It is passed through the pylorus, which is the valve between the stomach and small intestine until it reaches the jejunum, which is the middle part of the small bowel.

NJ-tubes are very easy to dislodge and pull out, and they can cause nasal irritation and ulceration. For these reasons, they are only used temporarily. Sometimes a patient only needs nutritional support to get through a difficult flare-up. Other times, a patient may benefit from a short course of rest to their gut. Another instance when an NJ-tube might be used is to determine a patient’s tolerance of tube feeding and/or types of formula. Sometimes, particularly with younger patients, doctors prefer to use an NJ-tube as a trial run before surgically placing a permanent tube. If the patient is responsive and begins thriving, then a permanent tube is a good option.

The second temporary tube is an NG tube (nasogastric). It is placed the same way as the NJ tube, although it stops in the stomach. In addition to being used for feedings, it can also be used to remove stomach contents, such as food, liquids and air. Gastroparesis patients usually do not utilize the NG tube for feedings, but for decompression and the removal of stomach contents.

Nutritional Support for CI

Although CI does not have a cure, it can often be managed with changes to a patient’s diet and medication. However, some patients will still not be able to maintain a healthy weight or nutritional status and maybe frequently hospitalized for dehydration and complications arising from malnutrition. For such patients, enteral nutrition (receiving nutrition through a feeding tube) can provide the nutrients and calories they need each day.

In many cases of CI, oral maintenance of nutrition is not possible.  Due to extreme nausea, vomiting, and pain, patients often experience severe malnutrition, weight loss, and dehydration. Having CI doesn’t mean a patient will need a feeding tube; it is only placed in the most severe cases that are not responsive to dietary and pharmacological interventions.

It is also important to remember that if a patient’s condition improves enough that they can maintain their weight and nutritional status through oral feedings, the feeding tube can be removed.

If following the recommended diets doesn’t work, and the patient suffers from chronic malnutrition, feedings through an IV line may be the only option for maintenance of nutrition.

There are two types of feeding:

  1.  Parenteral nutrition is nutrition fed through the vein, commonly referred to as TPN (Total Parenteral Nutrition).
  2.  Enteral nutrition is nutrition fed through a feeding tube that has been implanted into the stomach and/or small bowel.
pH Probe

It is common for people with gastroparesis to also suffer from severe acid reflux (GERD) as a result of food sitting in the stomach for so long. A pH probe is a test to determine the amount of acid in a patient’s stomach throughout the day.

Preparation:

Acid suppressants may be stopped the day before the test in order to ensure the most accurate results. Preparation involves the insertion of a very small tube through the nose and into the stomach. The tube is taped to the patient’s nose and connected to an external, portable machine that records pH levels throughout the day over a 24-hour period.

During the test:

This test can be an outpatient procedure and the patient is usually asked to maintain normal eating habits for this test. The patient is given a diary to document symptoms, the time of the symptoms, and whether symptoms are triggered by food or positional changes (sitting up, etc.).

After the test:

The patient will return to his/her physician to have the tube removed and return the diary. Normal activities may be resumed.

Results:

If the test is positive, it will indicate that the patient has higher than normal levels of acid in the stomach and therefore points towards a diagnosis of gastroesophageal reflux disease (GERD). Doctors typically treat that with medications such as proton pump inhibitors (Prilosec, Nexium, Prevacid, Aciphex) which reduce the amount of acid produced in the stomach. If the GERD is very severe and not controlled on medication, the patient may benefit from a Nissen Fundoplication.

Alternatives:

A more easily tolerable method of testing pH levels known as the Bravo Monitoring System is now available from Medtronic. It is the size of a capsule and is placed during an endoscopy. It will monitor pH levels for 48 hours with much less discomfort than is experienced in traditional pH monitoring.

Small Bowel and Multivisceral Transplant

Transplant is recommended under the following conditions:

Failure of home parenteral nutrition characterized by:

  • Impending or overt liver failure
  • Thrombosis of ≥2 central veins
  • Two or more episodes per year of systemic sepsis, particularly those requiring hospitalization with septic shock and fungal infections
  • Frequent episodes of dehydration requiring hospitalization

Pre-transplant evaluation is extensive, and most patients will meet with a multidisciplinary team that includes a transplant clinician, hepatologist, gastroenterologist, social worker, financial coordinator, nutritionist, and psychologist

Patient survival is approximately 80 percent at one year and just over 60 percent at five years.  As a result of surgical advances, control of acute cellular rejection, and a decrease in lethal infections, the rate of patient survival at one year now exceeds 90 percent at experienced centers.

There are essentially 4 types of transplants involving the intestine.

  • The first is the isolated intestinal transplant. This type of transplant consists of the small bowel (jejunum and ileum) and is given to patients who have a normal liver function or a liver with early/reversible liver disease and meet the criteria for intestinal transplantation.
  • The second type of transplant is the combined liver and intestinal transplant. This consists of two organs – the liver plus the entire small intestine together as one group. It is given to patients with irreversible liver disease and intestinal failure.
  • The third type of transplant is the multivisceral transplant. This transplant includes the liver, stomach, duodenum, pancreas, and small bowel. It is reserved for patients who have organ failure involving the liver, pancreas, and intestine or for patients with diffuse diseases of their intestines (such as Gardner’s Syndrome, intestinal polyposis, or motility disorders such as pseudo-obstruction) associated with liver disease.
  • The fourth option is a modification of the multivisceral transplant called the modified multivisceral transplant in which the liver is not included, and the stomach may or may not be included.

The organs transplanted are tailored to the patient’s needs.  During the transplant, your organs are removed, the new organs are placed, the blood vessels are attached, and an ostomy (either an ileostomy or colostomy) is created, and the skin is closed. An ostomy is an opening from inside the abdomen to the outside of the abdomen and is used for elimination of stool, as well as monitoring the new intestine for rejection. Depending on the type of intestinal failure, some ostomies are temporary, and others are not. If the ostomy is temporary and the patient remains stable, the bowel can be reconnected at a later time.

Post-transplant complications:

  • Technical complications can occur including bleeding, thrombosis, and anastomotic leaks.
  • Infectious complications (particularly bacterial infections) are common and remain the leading cause of death.
  • The incidence of rejection is high in intestinal transplantation compared with other organs, although there has been some degree of improvement in recent years.
  • Other complications such as GVHD and PTLD are less common.

The decision for transplant should not be taken lightly and patients should ensure that they are well informed.

SmartPill

The SmartPill Capsule Motility Procedure is an exciting advancement in gastrointestinal healthcare. SmartPill is a wireless, ingestible capsule that measures pressure, pH, and temperature data from your GI tract and wirelessly transmits that information to a data receiver worn on a belt or lanyard. This data is then downloaded to a computer, allowing your physician to analyze the information. SmartPill provides physicians with data for Gastric Emptying TimeCombined Small/Large Bowel Transit Time, and Whole Gut Transit Time.

With just one capsule, your physician can obtain the information needed to better evaluate your condition.

SmartPill is more comfortable and less invasive than many traditional GI procedures. The SmartPill procedure requires only a short 15-30-minute office visit after which you can return to your daily activities. With SmartPill, there is no exposure to radiation, and no hospital visit required as with traditional test methods.

For more information or to find a physician near you, contact SmartPill Corporation at info@smartpillcorp.com or visit www.smartpillcorp.com.

Total Parenteral Nutrition (TPN)

What it is:

TPN is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein. (http://medical-dictionary.thefreedictionary.com/total+parenteral+nutrition)

When is it used:

TPN is used when individuals cannot or should not get their nutrition through eating. TPN is used when the intestines are obstructed when the small intestine is not absorbing nutrients properly, or a gastrointestinal fistula (abnormal connection) is present. It is also used when the bowels need to rest and not have any food passing through them. Bowel rest may be necessary in Crohn’s disease, pancreatitis, ulcerative colitis, and prolonged bouts of diarrhea in young children. TPN is also used for individuals with severe burns, multiple fractures, and malnourished individuals to prepare them for major surgery, chemotherapy, or radiation treatment. Individuals with AIDS or widespread infection (sepsis) may also benefit from TPN. It is also used for patients who have gastroparesis and cannot digest food properly. (http://medical-dictionary.thefreedictionary.com/total+parenteral+nutrition)

Description:

TPN is normally given through a large central vein. A catheter is inserted into the vein in the chest area under local anesthesia and sterile conditions. Often the placement is done in an operating room to decrease the chance of infection. Several different types of catheters are used based on the reason TPN is needed and the expected length of treatment. Once the catheter is in place, a chest x-ray is done to make sure the placement is correct.

Normally TPN is administered in a hospital, but under certain conditions and with the proper patient and caregiver education, it may also be used at home for long-term therapy. TPN solution is mixed daily under sterile conditions. Maintaining sterility is essential for preventing infection. For this reason, the outside tubing leading from the bag of solution to the catheter is changed daily, and special dressings covering the catheter are changed every other day. (http://medical-dictionary.thefreedictionary.com/total+parenteral+nutrition

What the solution contains:

The contents of the TPN solution are determined based on the age, weight, height, and medical condition of the individual. All solutions contain sugar (dextrose) for energy and protein (amino acids). Fats (lipids) may also be added to the solution. Electrolytes such as potassium, sodium, calcium, magnesium, chloride, and phosphate are also included, as these are essential to the normal functioning of the body. Trace elements such as zinc, copper, manganese, and chromium are also needed. Vitamins can be included in the TPN solution, and insulin, a hormone that helps the body use sugar, may need to be added.  Adults need approximately 2 liters of TPN solution daily, although this amount varies with the age, size, and health of the individual. Special solutions have been developed for individuals with reduced liver and kidney function.

Successful TPN requires frequent, often daily monitoring of the individual’s weight, glucose (blood sugar) level, blood count, blood gasses, fluid balance, urine output, waste products in the blood (plasma urea), and electrolytes. Liver and kidney function tests may also be performed. The contents of the solution are individualized based on the results of these tests. (http://medical-dictionary.thefreedictionary.com/total+parenteral+nutrition)

Complications of TPN:

Mechanical:

Mechanical complications are primarily related to the initial placement of a central venous catheter. Improper placement may cause pneumothorax, vascular injury with hemothorax, brachial plexus injury, or cardiac arrhythmia.

Venous thrombosis is one of the two most common problems that occur after central venous access is established. The other is an infection.

Venous thrombosis is associated with significant morbidity rates. Signs include distended neck veins and swelling of the face and ipsilateral arm. The risk of venous thrombosis is greater if patients are dehydrated, have certain malignancies, have had prolonged bed rest, have venous stasis, have sepsis, or have hypercoagulation.

Additional risk factors include morbid obesity, smoking, or ongoing estrogen therapy. (http://www.rxkinetics.com/tpntutorial/)

Infectious:

TPN imposes a chronic breach in the body’s barrier system. The infusion apparatus from container to catheter tip may prove a source for the introduction of bacterial or fungal organisms.

Infection is one of the two most common problems that arise after central venous access is established. The other is venous thrombosis, discussed earlier. The mortality rate from catheter sepsis may be as high as 15%.

The primary preventive measures include adhering to strict aseptic procedure while establishing access and providing care of the dressing and line. (http://www.rxkinetics.com/tpntutorial/)

Metabolic:

Metabolic complications fall into two broad categories: early and late complications. Those in the first category occur early in the process of feeding and may be anticipated. They are avoided by careful monitoring and appropriate adjustment of intake. Late metabolic complications are less predictable. They may be caused by an exacerbation of preexisting abnormalities, unpredictable long-term requirements, inadequate solution composition, or failure to monitor adequately. (http://www.rxkinetics.com/tpntutorial/)

Fluid and electrolyte:

Electrolyte management is one of the most difficult aspects of PN therapy. Often electrolytes are outside of the normal range based on an underlying cause rather than directly related to the PN solution. For this reason, no specific guidance can be given to adjusting individual electrolytes based on laboratory serum concentration. Instead, incremental dose adjustments are made concurrent with the treatment of the underlying cause of electrolyte abnormality. In general, supplemental electrolyte doses in response to an acute underlying condition are best managed outside of PN therapy. (http://www.rxkinetics.com/tpntutorial/)

Refeeding syndrome:

Refeeding of severely malnourished patients may result in “refeeding syndrome” in which there are acute decreases in circulating levels of potassium, magnesium, and phosphate. The sequelae of refeeding syndrome adversely affect nearly every organ system and include cardiac dysrhythmias, heart failure, acute respiratory failure, coma, paralysis, nephropathy, and liver dysfunction.

The primary cause of the metabolic response to refeeding is the shift from stored body fat to carbohydrate as the primary fuel source. Serum insulin levels rise, causing intracellular movement of electrolytes for use in the metabolism.

The best advice when initiating nutritional support is to “start low and go slow”. (http://www.rxkinetics.com/tpntutorial/)

Upper GI

An upper GI is often performed to screen for things such as blockages and obstructions that may cause gastroparesis symptoms and slow down emptying. If an obstruction is a cause, the symptoms of gastroparesis should go away once the blockage has been cleared. Sometimes this test can indicate gastroparesis based on the amount of time it takes for the barium to leave the stomach.

Preparation:

Patients who are having an upper GI will be asked to not eat or drink after midnight the night before the test.

Before the test:

Upon arrival at the radiology department on the day of the test, the patient will be given several cups of barium (contrast) to drink within a certain timeframe.

During the test:

Once all the barium has been ingested, a series of images will be taken of the barium as it moves through the stomach and into the small bowel. This test can find problems such as blockages and tumors. In the case of gastroparesis, the transit of the barium may also be slow.

After the test:

It is not uncommon for stool to be white for a few days following the procedure. It is important to drink as much as possible following the test in order to get rid of the barium.  It can often become hard if it sits in the GI tract for long. Normal activity may be resumed immediately after the test.

Results:

Abnormal results may show an obstruction, tumor, abnormality of the stomach, or delayed emptying of barium.

TIP:

The flavor is not very appealing, but you may ask that the barium be flavored or request permission to suck on hard candy or a mint after each sip.

Abdominal X-Ray

An abdominal x-ray is a quick, basic test to determine if there is a current obstruction, blockage, unusual air pattern, or ileus in the small bowel. This test only takes a few minutes to complete and is not invasive. It is often the first test used to look for the cause of abdominal pain, distention, nausea, and vomiting.

Before the procedure:

There is usually no preparation required. Patients who think there is any chance they are pregnant should inform the technician before the procedure. Also, he/she should notify the radiologist of any recent tests involving contrast dye or barium as this could affect the ability to read the results.

During the procedure:

The patient will be asked to wear a heavy, protective covering in order to reduce exposure to radiation. Images may be taken as the patient is lying down and/or sitting up. Often, he/she will be asked to hold his/her breath as the images are being taken. Typically, only two pictures are taken, but more may be needed upon review. Abdominal x-rays usually only last 5-10 minutes.

After the procedure:

As long as there are no emergent issues that show up in the x-ray, normal activities may be resumed.

Results:

Abnormal results may indicate an obstruction, blockage, or tumor. It can show abnormal air/fluid patterns and occasionally, gall stones. Sometimes an abnormally thick bowel will be apparent.

Barium Follow-Through

A barium or small bowel follow-through is a good test to indicate the presence of an obstruction, blockage, or pockets of air in the small bowel, as well as determining the rate at which the small bowel moves barium.

Preparation:

The patient will be asked to remain on a clear liquid diet the day before the test. He/she may also be asked to use enemas the night before the test in order to ensure that the small bowel is clear of food which may interfere with test results. The morning of the test, it is usually recommended that diabetics only take 1/2 of their insulin. Other necessary medications may be taken with a small sip of water.

Before the test:

The patient will be given approximately three cups of barium to drink. Barium is a chalky like substance which shows up under a fluoroscope to help identify the location and type of problem that may exist.

During the test:

While laying on his/her back, images will be taken at specific intervals as the barium empties from the stomach, into the small bowel, and throughout the colon. Depending on the rate of emptying, this test could take anywhere from 1-5+ hours.

After the procedure:

The patient may resume normal activities. It is important to try to have bowel movements as early as possible because the barium can become hard and difficult to pass with time. The stool may be white for several days following the procedure until the barium has passed.

Results:

Results are typically available the next day. Abnormal results may show a blockage, obstruction, tumor, abnormality of air/gas pattern, or slow lower GI motility.

CIP Causes

CIP can be secondary to a known underlying disease process or disorder including:

          – Cystic Fibrosis

          – Diabetes

          – Dysautonomia

          – Mitochondrial Diseases- affects at least three major organs and can explain why a person may have a                 number of seemingly unrelated problems

          – Autoimmune Disorders (Scleroderma, Lupus)

          – It can also be idiopathic (without a known cause).

CIP may be apparent from infancy or may surface later in life. Sometimes it follows an acute illness or surgery. Children with CIP are generally born with the condition.

Acute (temporary) pseudo-obstruction can be a result of certain medications, recent surgery, or prolonged bed rest and may be diagnosed as “acute colonic ileus.”

The symptoms of intestinal pseudo-obstruction are caused by a problem in how the muscles and nerves in the intestines work. When tests show that the dysfunction is caused by unsynchronized contractions, the disorder is classified as neurogenic (arising from the nerves). If the dysfunction is caused by weak or absent contractions, the disorder is classified as myogenic (arising from the muscles).

CIP Testing

Diagnosis is often difficult as CIP can closely mimic more common illnesses. Diagnosis is not based on a singular test but is instead based on a combination of symptoms, clinical features, and tests that exclude actual bowel obstruction and/or any other structural abnormality.

Intestinal manometry can provide more specific information about the nature and extent of the underlying dysfunction but is not widely available and is not required for diagnosis.

Other tests that may also aid in diagnosis might include (but are not limited to) abdominal x-ray, CT Scanbarium follow-through, and intestinal biopsy.

Colonoscopy

Endoscopy

Often patients with gastroparesis will undergo a colonoscopy to check for blockages, inflammation, abnormal twisting of the bowel, or other problems.

Preparation:

The patient will be instructed to remain on a liquid diet for up to 24 hours before the procedure. In addition, the patient will be required to perform some form of bowel prep whether it is an enema or laxative. Both steps are crucial in order to ensure that the tissues are visible during the procedure.

Before the test:

It is usually necessary for the patient to arrive at the hospital 30 minutes to an hour before the test. The medical staff will review medical records, allergies, and monitor blood pressure and temperature. The patient will be placed on a heart monitor and given an IV in preparation for IV sedation. Once taken to the procedures room, sedation medications are started, and the patient is instructed to lay on his/her left side.

During the test:

While under sedation, the physician performing the procedure will gently place a scope with a camera through the rectum and into the colon. Air is inserted into the bowel in order to make the tissues more visible. The scope will then be guided through the large bowel into the opening of the small bowel. Tissue samples (biopsies) are taken, and images are recorded for further review and documentation.

After the test:

The patient is returned to a recovery area to be monitored until he/she is alert and able to drink sips of water or juice. Driving is restricted for 24 hours, so the patient must be accompanied by a friend or family member. It is recommended that a soft diet be followed for the remainder of the day. Common side effects include nausea, bloating, fatigue, and gas due to the air inserted during the procedure. Bleeding, fever, bowel perforation, or pain are uncommon, but should be reported immediately.

Results:

Some results are available instantaneously. Biopsies will be sent for review and may not be available for several days.

 

Electrogastrogram

An EGG is a fairly simple test that is not performed at most hospitals but is a great way to document a patient’s nausea. An EGG, or electrogastrogram, is basically like an EKG or EEG of the stomach.

Preparation:

Usually, the patient will be asked to eat a small meal a couple of hours before the test (such as toast and OJ). It is often performed in conjunction with the gastric emptying scan.

Before the test:

The patient is placed in a recliner or on a gurney and instructed to relax. Electrodes, similar to those used in EKG’s or EEG’s, are placed on the skin in the area of the stomach.

During the test:

The technician records the electrical activity of the stomach for a certain amount of time. The patient will then be asked to drink water. Before the test, and at ten-minute intervals during the test, the technician will document the patient’s symptoms.

After the test:

There are no restrictions, and the patient may return to normal activity.

Results:

Normal activity is 3 cpm (cycles per minute). Patients with nausea and/or vomiting will often show gastric dysrhythmias such as tachygastria (too much activity), bradygastria (too little activity), or mixed dysrhythmias (tachygastria and bradygastria). An abnormal EGG may or may not be present in gastroparesis and can be used for a variety of GI motility disorders (such as functional dyspepsia), or for patients with no known GI disorder who are suffering from unexplained nausea and/or vomiting.

Doctors and technicians at any hospital can learn how to record EGG’s and analyze results. More information can be obtained by contacting the company listed below.

3CPM Company
P.O. Box 431
Crystal Bay, NV 89402
1-877-327-6344 (toll free)
1-775-833-0129 (fax)
threecpm@aol.com (e-mail)

 

Enterectomy

An enterectomy is the surgical removal of a portion of the intestine. It is performed using general anesthesia.

The procedure can be done as either laparoscopic or open surgery, depending on your case.

If you have laparoscopic surgery, you will have three to five small cuts in your lower belly. The surgeon will pass a camera and medical instruments through these cuts. You may also have a cut of about 2 to 3 inches if your surgeon needs to put a hand inside your belly to feel the intestine or remove the diseased segment.

If you have open surgery, you will probably have a cut about 6 inches long in your mid-belly.

In both kinds of surgery, if there is enough healthy small intestine left, your surgeon will sew or staple the healthy ends of the small intestine back together. Most patients have this done.

If you do not have enough healthy small intestine to reconnect, your surgeon will make an opening called a stoma through the skin of your belly. Your small intestine will be attached to the outer wall of your belly. The stool will go through the stoma into a drainage bag outside your body. This is called an ileostomy. The ileostomy may be either short-term or permanent.

Risks include:

– Blood clots
– Breathing problems
– Bleeding
– Heart attack or stroke
– Infection
– Bulging tissue through the incision, called an incisional hernia
– Damage to nearby organs in the body
– Many episodes of diarrhea
– Problems with your ileostomy
– Scar tissue that forms in your belly and causes a blockage of your intestines
– Short bowel syndrome (when a large amount of the small intestine needs to be removed), which may lead to       problems absorbing important  nutrients and vitamins
– The ends of your intestines that are sewn together comes apart (anastomotic leak)
– Wound breaking open (dehiscence)

http://pennstatehershey.adam.com/content.aspx?productId=117&pid=1&gid=002943

Esophageal Manometry

Esophageal manometry is a test that measures the activity of the lower esophageal sphincter as well as pressure and contractions in the esophagus. The lower esophageal sphincter is located near the lower portion of the esophagus and helps prevent stomach acid from coming back up. This test is usually performed for people complaining of symptoms such as heartburn, chest pain, and/or difficulty swallowing. It is also used in people who may develop aspiration pneumonia due to the acid backing up into the lungs.

Preparation:

The patient may be asked to avoid food or liquid on the day of the test. In addition, certain medications may be stopped in advance in order to ensure accurate results.

During the test:

The esophageal manometry is performed by placing a small tube through either the patient’s nose or mouth. The tube is guided down through the esophagus to the lower esophageal sphincter where it measures the pressure and contractions after dry swallows and swallows with sips of water. It can detect problems such as esophageal spasms, lack of muscle coordination, and other conditions that may be present in gastroparesis.

After the test:

The patient may experience some throat pain or nose pain from the tube placement. Bleeding is rare but should always be reported. Normal activities may be resumed.

Results:

Abnormal results indicate a problem with the muscular function of the esophagus. It can explain heart attack-like symptoms and difficulty swallowing.

Feeding Tubes

Deciding if you need a feeding tube

Making the decision to tube feed is never an easy one. Tube feeding can be a scary prospect, but it doesn’t have to be.

Things to consider

You do not have to stop eating orally just because you have a feeding tube. If you can safely eat and drink, then you can continue to do so after receiving a feeding tube.  This will depend on the reason for the tube and the motility in the gut.

Feeding tubes are not always permanent, however, it is often difficult to estimate how long a feeding tube will be needed.

Tube feeding does not limit you.  You can still continue with your normal activities and work.  Many adults work while their tube feeds are running.

You are not alone. There are numerous adults who have feeding tubes.

G/J Tubes

When a permanent tube will be used, the primary type used is a J-tube (jejunal). J-tubes are placed directly into the small intestine and can be placed either percutaneously, laparoscopically, or surgically via a laparotomy.

percutaneous J-tube (PEJ) is placed through the skin and into the small intestine via endoscopy. The doctor advances a lighted scope down past the duodenum. When the light can be seen through the abdomen, the doctor then punctures the abdomen in that spot and places the J-tube through it. It is anchored by a hard bumper on the inside. After the procedure, the patient usually goes home, or will only stay overnight.

Feedings can be started at a slow rate within 4-12 hours after the procedure. Jejunal feedings are administered around-the-clock through a pump. Depending on the caloric needs of a patient, and whether or not he/she is able to take in supplemental nutrition orally, feeds might be limited to overnight or a certain number of hours a day. Portable pumps and backpacks are available, making it possible for a patient to be active and mobile.

When a J-tube is placed by laparoscopy, it is a minimally invasive surgery. A laparotomy entails an open surgical procedure. Both place the J-tube into the small bowel in a different manner than a PEJ. They are generally anchored by a balloon, and sometimes a few sutures. Balloons can burst from pressure and spasms in the small bowel, which means the J-tube can suddenly fall out. If that happens, the patient must get to the hospital as soon as possible because the stoma, the opening which the tube was placed into, can close very quickly. A surgeon or interventional radiologist may not be available to replace the tube at that point, but a temporary tube will be placed into the stoma in order to keep it open until it can be replaced.

Surgical placement of a J-tube requires a hospital stay of at least 3 days. Feedings are not usually started for 24 hours, which allows the small bowel to awaken following anesthesia. The feeding rate is usually started off slowly, and gradually increased. The patient is released once an adequate feeding rate is achieved. All patients with feeding tubes are placed under the care of a home health agency that can provide feeding pumps, supplies, and instruction in their use.

The final type of tube is the G/J-tube (gastro-jejunal). The G/J is a percutaneously placed combination tube, a PEG/J. A g-tube (large lumen) is placed into the stomach in the same manner that the PEJ was placed. Once the g-tube is in place, a smaller lumen tube is threaded to it and into the jejunum. The PEG/J has 2 ports on the end of it. One runs to the stomach and the other runs to the small bowel. The G/J tube has the advantage of allowing a patient to administer medicine through the gport, and to decompress the stomach, even while feeding through the jport. The stomach can be relieved of air or fluid by draining the contents into a bag. This could also be accomplished by a separate g-tube (PEG tube) for those with a j-tube, but the G/J eliminates the need for 2 separate incision sites.

Patients who have a G/J can usually go home on the same day, or after an overnight hospital stay.

Complications

Complications can include, pain, granulation tissue at the stoma site, bowel obstruction, intolerance of the feeding, abdominal infections, and peristomal infections. G/J-tubes have a slightly lower risk of abdominal infection since the stomach is punctured and not the small intestine. However, the complications from enteral tubes are generally less serious than those of parenteral nutrition, making it a better option for long term nutritional support.

Tubes Are Not Just for Feeding!

Feeding tubes can also be used to manage the symptoms of Digestive Tract Paralysis, and not for nutritional purposes only. Gastric secretions and undigested foods can accumulate in the stomach, causing nausea, fullness, pain, discomfort, and gas. By venting or decompressing the stomach, symptom relief can occur.

As a temporary measure, an NG can be placed through the nose and into the stomach. This is sometimes done during a flare-up that requires hospitalization. For a more permanent solution, a g-tube can be placed percutaneously (PEG). This is usually done in conjunction with a J-tube or PEJ but is not necessary. Some patients can maintain adequate oral intake but struggle with severe nausea and gas. A separate PEG can be very helpful for them. The option of a G/J tube, as described earlier, combines the nutritional support of a j-tube with the abdominal relief provided by a PEG.

Gastric Emptying Study

The gastric emptying study is the most commonly used test to diagnose gastroparesis. There are several variations of the test depending on which medical center performs it.

Preparation:

For this test, the patient is instructed to not eat or drink anything after midnight the night before and to avoid certain medications the day of the test. Some meds can affect the accuracy of the test results.

Before the test:

Before the test, the patient is given a meal with a trace of radioactive markers in it. The most common food used is eggs and toast, but often oatmeal or other foods are provided. A small amount of water or juice may also accompany the meal. This meal should be eaten within a certain timeframe in order to ensure the most accurate results.

During the test:

The GES typically lasts anywhere from 90 minutes to 6 hours. Images of the rate at which the food is digested are taken at certain intervals, often at the first half-hour, then every half hour-hour after that. In most instances, the patient is allowed to return to the waiting room in between images. It is believed that 4-6-hour tests are the most accurate. Many people may have normal results with the 90-minute test but show delayed emptying during the 4-6-hour version.

After the test:

Nothing is required after the test is over. The patient may return to normal meds, activity, and eating as instructed by his/her physician. Test results may take a couple of days to analyze.

Results:

A negative result means the meal moved through the stomach at a normal rate and is not suggestive of gastroparesis. If the results are positive, gastroparesis is the first suspicion and the physician may request additional testing to rule out additional causes for delayed emptying such as blockages, certain medications, or tumors.

Gastroparesis Treatment Options

Unfortunately, treatment for gastroparesis is limited. There are few medications available, most of which treat symptoms of nausea, vomiting, pain, and reflux, but do not treat the underlying causes which keep the stomach from digesting properly. For this reason, they are often ineffective. The FDA has been hesitant to approve motility drugs out of fear of cardiac-related complications, although studies into this are not well substantiated. Zelnorm was pulled from the market even though only .1 % out of 900,000 experienced any side effects, far less than the 3% who have complications from the commonly prescribed Reglan.

Most people try to manage their GP through diet changes. Eating six small meals a day of high-calorie foods is easiest on the stomach. In spite of this, a patient may still experience extreme symptoms. Some patients cannot even hold down small sips of fluid, while others do well on small pieces of fish, chicken, and potatoes.

When diet modification and medications do not work, more extreme options include tube feedings and IV nutrition. Certain surgical procedures may be performed to help with some gastroparesis related complications. The introduction of Enterra Therapy by Medtronic is currently the only surgical option actually geared towards helping control nausea and vomiting.

In the most extreme cases, a full or partial gastrectomy may be necessary, or when the small bowel is also affected, a multi-visceral (4 or 5 organs) transplant may become the only remaining option.

Gastroparesis Symptoms

Symptoms of Gastroparesis often imitate those of other GI disorders which can make diagnosis difficult. Patients may complain of one or more of these symptoms:

Early Satiety after a few bites of food

Nausea (especially after eating)

Vomiting (often undigested food from hours or even days before)

Abdominal Pain

Hiccupping

Excessive Belching

Bloating

Weight Gain

Weight Loss

Loss of Appetite

Malnutrition

Dehydration

Heartburn or gastroesophageal reflux which is not controlled by acid suppressants

Erratic blood glucose levels

Hooking Up

A feeding tube comes with a lot of new equipment and supplies.

Feeding Pump and Bags:

There are two main pumps available in the United States: the Covidien Kangaroo Joey and the Moog EnteraLite Infinity.

The Covidien Kangaroo Joey allows a patient to feed and flush while hooked up. There are feed and flush bags available. A patient can fill one bag (with the purple cap) with the formula, and place sterile water in the second bag (with the blue cap). After the bags are primed, which is important to get all the excess air out of the bag to prevent painful air bubbles from entering the small bowel, a patient can then input their feed and flush requirements into the Joey. Total formula volume would be entered, followed by feeding rate, and then the total flush volume would be entered, along with how often it should occur. This is very handy for overnight use, or when patients are not ambulatory. Instead of having to get up in the middle of the night, disconnect, fill a syringe, flush, and then re-connect, a patient can stay sound asleep and have the pump stop the formula, run the water flush, and then re-start formula feeding.

The Joey pump has many more electronic options than the EnteraLite. One popular feature is its ability to Auto Prime. With a touch of a button, the air will be forced out of the bag and the formula advanced down the line automatically. The machine stops priming when there are about 6″ of tubing left. This is to prevent the formula from spilling out the connector. All a patient has to do is manually hold the Auto Prime button for a few seconds to completely purge out the air and bring the formula to the end of the connector.

The Moog EnteraLite Infinity does not have the feed and flush option that the Joey does. It also doesn’t auto prime. Once the formula is poured into the bag, a patient must snap on the cap, turn the bag upside down to force the air to the top, and then manually pinch the longer end of the cartridge, slowly advancing the formula down the line.

Although it is more time consuming and requires hand strength, the Infinity drives out air much more effectively than the Joey. This allows the Infinity to be used in any position, even upside down. For active adults, this is very important. It is also extremely important for toddlers, children, and teens that roll around, hang from jungle gyms, and toss their feeding backpacks into various positions and configurations. The lighter weight and smaller size of the Infinity make it easier to transport and camouflage. It can be placed in waist packs, purses, and cross-body bags.

The pump that is right for you will depend on your feeding requirements. Some suppliers also only carry one brand of pumps, and some insurers only cover one brand.

Syringes:

There are many different types and sizes of syringes.  A catheter (large, long tip) or slip tip (short, thin tip) syringes are good choices to start.  Syringes come in a variety of sizes ranging from 1 ml to 60 ml.

Syringes may or may not be covered by insurance.  Some pharmacies will give them out for free with medications. Syringes can be reused at home.  They can be washed with soap and hot water and rinsed well.  Do not put syringes in the dishwasher.

Tape:

There are many types of tape with varied uses.  Some common ones are:

Hypafix: This is a thin, flexible, breathable cloth tape that must be cut with scissors.  It has a stronghold (does not rip apart) even when wet but is gentle on the skin.  It works well for securing NJ-tubes.

Micropore: Micropore (also known as paper tape) is a gentle adhesive that comes off easily when wet.  It is extremely versatile and works well for securing J-tube or G/J-tube extension sets to the skin.

Medipore: Medipore is a light, thin, flexible, breathable cloth tape that is similar to Hypafix except that it is pre-perforated, so no scissors are necessary.  This adhesive is not quite as strong as Hypafix but does work well and is gentle on the skin.

Duoderm:  This dressing can be used as the base on the face for those who use NJ tubes.  It works well to protect the skin from the daily irritation of the NJ tube.  Patients can place it on the cheek where the tube needs to be, place the NJ tube, and then use a layer of another type of adhesive over the top to secure the tube.  It protects the cheek from getting a groove in it from the tube and is very gentle on the tender skin of the cheeks. It is a soft and pliable gel adhesive that sticks well to clean, dry skin and when removed, is very gentle on the skin.

Tegaderm: Tegaderm is a very thin, clear dressing commonly used to cover things like IVs and accessed ports. It is fabulous as an NJ tube adhesive.

Durapore: This is a silky cloth tape with a very strong adhesive.  It tends to be irritating on sensitive skin but has a stronghold until it gets wet.  It can be used for taping NJ tubes and extension sets to clothing.

There are multiple securement devices that can be used to stabilize and hold your tube in place.  Some options are Bard Stat-Lock Device, Hollister Tube Attachment Device, and Grip-Lock.

Intravenous Nutrition

TPN is used when all or part of a person’s digestive system does not work. A person may need TPN because of a gastrointestinal (GI) disorder that severely limits the ability of their digestive tract. A person may not be able to swallow food, move the food through the digestive system, or absorb nutrients from the food.

With TPN, a special intravenous (IV) line is inserted into a vein, and nutrients are delivered directly into the bloodstream.   The catheter is typically placed in a large vein in the chest and can stay in place for a long period of time if needed. There are many different kinds of catheters that can be placed based on doctor/hospital preference and the needs of the patient.

Type of Catheters

There are numerous types of catheters available with single or multiple lumens (ports) to allow for simultaneous infusion of multiple fluids and/or medications.

A tunneled catheter (ex. Hickman, Broviac, Leonard) is a type of catheter that is tunneled under the skin and put in place either in a radiology department or in an operating room.  A tunneled catheter can be left in place for as long as needed.

A Peripherally Inserted Central Catheter (PICC) is commonly used in patients who require therapy for a short duration, usually for several weeks to a few months.  A PICC may be placed at the patient’s bedside while in the hospital or by the radiology department.

Ports are often used for patients requiring months to years of therapy and are commonly used where intermittent infusion therapy is needed. A port usually only needs care when it is accessed. A port is accessed by using a special needle inserted through the skin and into the port hub.  Ports are well-liked because they are fairly inconspicuous when not accessed. Placement of a port usually occurs in an operating room or by a Radiologist with X-ray guidance.

Timing

In some cases, IV nutrition is used temporarily until a person is able to tube feed again. In other cases, TPN becomes the main and/or only form of nutrition.  The amount of time a person requires TPN varies.  TPN can be given for as long as is needed and it can be given to all ages, including infants and children as well as adults.  There are many people who live very well on TPN for many, many years.

The length of time that TPN is infused depends on each individual’s needs and is determined by your team of doctors.  It can run anywhere from 10-24/hrs. per day, most individuals run their TPN at night to allow freedom during the daytime.

TPN is more costly and dangerous than enteral feeding and every attempt should be made when possible to use the enteral path first.

Medication for Gastroparesis

Unfortunately, medications to treat gastroparesis are limited. Most of them are used to treat symptoms and not the underlying disorder which limits effectiveness.

Aciphex– Used for GERD.

Ativan – used to control nausea but causes extreme drowsiness.

Bethanechol – Used to stimulate esophageal motility.

Compazine– Used to control nausea, but can cause drowsiness, restlessness, etc.

Domperidone– Not FDA approved, but still available at compounding pharmacies in the US, or in other countries.   It may cause a prolonged QT interval on the EKG which can lead to sudden cardiac arrest, especially when used in conjunction with certain other medications.

Erythromycin– Often used for motility, but typically is not very effective especially if not taken with nausea meds. It may cause a prolonged QT interval on the EKG which can lead to sudden cardiac arrest, especially when used in conjunction with certain other medications.

Marinol– Approved Marijuana drug that is given to chemo patients or others with severe nausea.

Nexium– Used for GERD as well as for healing an esophagus damaged by acid.

Periactin (cyproheptadine)– Used to relax the pyloric sphincter and as an appetite stimulant.

Promethazine– Used for nausea but can cause drowsiness and restlessness.

PrevacidPrilosec- Used for GERD.

Reglan– Used for nausea relief and to increase motility.  Unfortunately, it is not very well tolerated by many patients and currently has a black box warning from the FDA.

Tricyclic Antidepressants (Elavil, nortriptyline, etc)– in small doses, these can help with nausea.

Zofran– Used for nausea.

Nutritional Support

In some cases of gastroparesis, oral maintenance of nutrition is not possible. Due to extreme nausea, vomiting, and pain, patients often experience severe malnutrition, weight loss, and dehydration. Potassium tends to drop quickly which can lead to serious complications including sudden cardiac death. Other common nutrients easily affected are calcium, iron, magnesium, and phosphorous. Typically, vitamins and minerals are not well tolerated orally so supplementation is often difficult.

If following the recommended diets don’t work, and the patient suffers from chronic malnutrition, feedings through an IV line or G/J-tube may be the only option for maintenance of nutrition.

Although tube feedings are safer than IV Nutrition (TPN), they are usually not effective in people who suffer from problems of the lower GI tract. They are most commonly used in cases of Gastroparesis, although they can also be used to help the stomach and/or small bowel decompress and prevent vomiting.

Some individuals and children may be unable or unwilling to eat because of the severity of their disorder or they may be unable to maintain basic nutritional requirements even with supplementation and diet adjustments. In such cases, individuals are put on enteral or total parenteral nutrition (TPN).

Nutritional Support for CIP

Some individuals and children may be unable or unwilling to eat because of the severity of their disorder or they may be unable to maintain basic nutritional requirements even with supplementation and diet adjustments. In such cases, individuals are put on enteral or total parenteral nutrition (TPN).

Parenteral nutrition is nutrition fed through the vein, commonly referred to as TPN (Total Parenteral Nutrition).

Enteral nutrition is nutrition fed through a feeding tube that has been implanted into the stomach and/or small bowel.

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Small Bowel Manometry

Small bowel manometry is the most common test used to diagnose CIP, but it is not always definitive and not available at many hospitals. Although it sounds like a difficult procedure, it is actually considered to be one of the easier ones in the diagnosis of CIP.

Preparation:

The patient will be instructed to not eat or drink after midnight the night before the test.
Certain motility and antispasmodic medication should be stopped a day or two before the procedure. This is to ensure an accurate diagnosis and a full understanding of the condition without the use of medication. Crucial medications may be taken the morning of the test with a small sip of water.

The patient may need to stop all non-essential medications for up to two days following the procedure. This includes pain medications and anti-anxiety drugs.

Diabetics may only need to take half of their insulin the morning of the test.  Please check with your doctor if you are diabetic.

During the procedure:

The procedure is similar to an esophageal manometry. The patient will be given numbing medication for his/her throat and a tube will be guided down into the small bowel. During the test, the patient will be given a meal in order to measure the contractions of the small bowel after eating. Often these contractions are not coordinated. In some instances, the small bowel contracts backward or stops contracting at all. After about 6 hours, the tube is removed from the patient’s mouth.

There is also a 24-hour version of this test, in which case the patient will remain in the hospital overnight or will be asked to return the following day for removal of the tube.

After the procedure:

The patient may have a sore throat, excessive gas, and slight bleeding. Normal activities may be resumed. Movement is recommended to help relieve any gas pressure. Any extensive bleeding, excessive nausea, vomiting, pain, or fever should be reported immediately.

Results:
Results will be evaluated by a physician within a few days. Abnormal results indicate pseudo-obstruction, a tumor, or other motility problems in the small bowel. It can be helpful in the diagnosis of CIP.

Surgical Intervention for CIP

Surgery should be performed rarely, if at all because intestinal pseudo-obstruction is a generalized disorder that typically affects the entire intestine. Removing part of the intestine cannot cure the disease.  Only rare cases can benefit from surgical resections.

The role of surgery in the management of CIP is to provide access to the stomach or small bowel for venting (decompression to relieve symptoms) and feeding, both of which may be performed laparoscopically.

Some individuals with CIP may be treated by intestinal decompression, a procedure that reduces the pressure within the GI tract. Intestinal decompression is most commonly performed by inserting a tube (such as a J-tube) within the intestines in order to decompress abnormally swollen (distended) segments of the intestines. Gastrostomies (G-tube) and enterostomies can effectively decrease retching, vomiting, and abdominal distension and represent a possible option in patients who can be fed by enteral nutrition. By decompressing the areas of distention, improvement may be seen in nutrient absorption, while also decreasing the need for frequent hospitalizations and repeat surgeries. 

Rarely, and in very specific and severe cases of CIP, surgery to remove a section of the intestines (enterectomy) may be necessary. Because surgery can potentially worsen CIP, it only has a limited role in the treatment of specific cases. When CIP is limited to an isolated portion of the bowel, surgical bypass of the affected segment may be beneficial. Certain surgeries can potentially decrease the frequency of certain symptoms such as retching, vomiting, and abdominal distention.

Pacing of the intestine and electrical stimulation of the intestine is considered experimental at this time.

Surgical complications can and do occur.  In fact, surgery can make the situation and underlying disease worse and should be performed only if absolutely necessary. It is important to have a thorough and informed discussion with your surgeon and regular doctor before making a decision to pursue surgery.

Tube Feeding Formula

What type of formula may be fed into the small intestine?

While technically any standard tube feeding formula may be used, most people are started on formulas that are already predigested or broken down into their elements.  These are typically digested and absorbed much better in the jejunum. 

There are over 100 commonly used brand names of commercially prepared formula available, so there is no shortage of options to choose from when you and your doctor, or nutritionist, decide which formula is right for you.

An easy way to distinguish all the different types of commercial liquid nutrition is by their fat, carbohydrate, and protein (or macronutrient) sources. Using this method, there are three different categories of formulas: standard, elemental, and specialized.

Standard formulas are the most commonly used. They contain proteins that haven’t been broken down (intact proteins) and polysaccharides.

Standard formulas are intended for patients who are able to absorb and digest nutrients without difficulty. Their goal is to provide the entire spectrum of macro-and micronutrients necessary for human nutrition.

Examples include Ensure, Boost, or Carnation Instant Breakfast.

Elemental formulas (also known as monomeric, hydrolyzed, or chemically defined formulas) are different from standard formulas because their macronutrients have already been partly or fully broken down for those patients who have compromised digestive systems or nutrient absorption problems.  This allows the body to digest and absorbs what it needs from the formula more easily.  J tube patients usually eat elemental formulas.

Examples include Optimental, Pivot, Tolerex, and Vivonex.

Specialized formulas are prescribed to address specific disease categories, profiles, and/or allergies.

Examples include Ensure, TwoCal, and Boost, Vivonex, Perative, Pivot, Tolorex, Vivonex TEN.