Botulinum Toxin Injections for Treatment of Diabetic Gastroparesis

Author: V. Dimov, M.D., Department of General Internal Medicine, Cleveland Clinic

A 75 year-old African American female with diabetic gastroparesis is admitted to the hospital with generalized weakness, N/V and hematemesis for 2 days.

PMH:
DM2, ESRD on CAPD, HTN, Depression, Diabetic gastroparesis, Diabetic ulcer of LLE

Medications:
Norvasc, Metoprolol, Lisinopril, ASA, Paxil, Lyrica, Neurontin, Clonidine, Colace, Percocet, NPH, SSI

Physical examination:
Obese in NAD, VSS
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Distended, decreased BS, NT
Extremities: LLE diabetic ulcer, no pitting edema

Laboratory results:
Anemia of chronic disease, Hgb 10.5 (at baseline)

What would you do?
Monitor H/H and VS
EGD

What is the most likely diagnosis?
Diabetic gastroparesis
Gastritis
PUD

What happened?
Hgb and VS were stable.
EGD was non-diagnostic due to the presence of large amount of food in the stomach.

The patient was placed on a full liquid diet and the EGD was repeated in 36 hours, it showed multiple gastric erosions with the largest one measuring 1.5 cm, no active bleeding.

The patient was not able to tolerate metoclopramide (Reglan) in the past due to lethargy and dyskinesia. She continues to have nausea and occasional vomiting.

What are the treatment options?
Erythromycin can be used for treatment of patients with diabetic gastroparesis but the evidence for its benefit is weak. In several small studies, improvement was reported by 43 % of patients. Erythromycin increases the risk of sudden death due to long QT syndrome, especially when used in patients taking medications that inhibit cytochrome P450.

Injections with botulinum toxin (Botox) into the pyloric sphincter can improve gastric emptying and symptoms.

What happened next?
A GI consult was called and he recommended a repeat EGD with botulinum toxin injection. After the the procedure, the patient was able to tolerate liquid diet which was then advanced to mechanical soft. Nausea and vomiting resolved. She was able to eat regular diabetic diet and was discharged home 2 days after the procedure.


Figure 1. Stomach filled with food (left); Botulinum toxin was injected in a 4-quadrant fashion in the pylorus (right).


Figure 2. EGD procedure report.

Final diagnosis:
Diabetic gastroparesis in a patient who cannot tolerate metoclopramide. Botulinum toxin injections for treatment of diabetic gastroparesis.

Summary:
Injections with botulinum toxin (Botox) into the pyloric sphincter can improve gastric emptying and symptoms in patients with diabetic gastroparesis who do not respond to standard treatment with prokinetic agents and/or are not able to tolerate such medications.

The safety and long-term efficacy of botulinum toxin injections for this condition has not been well established. In one study of 115 patients, 43% had a response to botulinum toxin treatment that lasted a mean of approximately 5 months.

References:
The Treatment of Diabetic Gastroparesis With Botulinum Toxin Injection of the Pylorus. Diabetes Care 27:2341-2347, 2004.
Endoscopic pyloric injection of botulinum toxin A for the treatment of refractory gastroparesis. Gastrointest Endosc. 2005 Jun;61(7):833-9.
Treatment of delayed gastric emptying. UpToDate 14.3 (paid subscription required).

Created: 11/11/2006
Updated: 11/13/2006