Eat Happy!

Eat Happy!

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Wednesday, April 16, 2014

The FOUR Dysmotility Components of the Stomach

(emptying, accommodation, pylorospasm, sensory)

Johns Hopkins PDF link that talks about Gastroparesis and discusses all four components expressing a basic understanding of dysmotility

We had an interesting talk with the motility doctor about the four issues that can cause issues on the stomach. Ian has chronic conditions affecting all four of these.

1) Accommodation:

Ian’s has had a fundoplication. When this happens, the top of the stomach (fundus) is wrapped around the base of the esophagus and stitched together (“plicated”). When this happens, the size and shape of the stomach are permanently altered. The fundus is essentially taken away. This is the part of the stomach that contracts to help move forward down through the stomach. Without it, the stomach is already at risk of emptying troubles. Ian’s stomach is unable to accommodate the volume that it did before the fundoplication. While our stomachs stretch to accommodate a large meal, Ian’s is unable to do that to the degree that an unaltered stomach would be able to do. Ian is not on any special medication to help with accommodation other than the motility medications to help move food along, in order to make room for “new” food to enter.


It is easy to see in this picture how the stomach decreases in size as the fundus (the top portion of the stomach) is used for fundoplication.




2) Emptying:

It is not new news that Ian’s stomach has trouble emptying. In his recent gastric emptying scan, he emptied 35% of his stomach in the first hour. Within two hours, he had emptied 51%. Ian was taking his motility medications for the study. The motility doctor wanted to see how well his medication was working. After the first two hours, they took another picture at three hours and then again at four hours. After four hours, Ian’ stomach had only emptied 58%. This means between the second and fourth hours, Ian only emptied 7%. This is because his motility medication, erythromycin, works for around two hours. After two hours, the efficacy declined considerably. It is meant to be a short acting medication. The 58% emptying in two hours is not bad, but the 7% emptying in the subsequent two hours is unfavorable. A normal scan would have shown 90% emptied after four hours.

Ian is taking erythromycin and bethanechol to help empty his stomach. The erythromycin works by adding some strength to existing contractions to help move food through the stomach. The bethanechol helps by tightening the upper esophageal sphincter, the valve at the base of the esophagus that leads into the stomach, By tightening this sphincter muscle, the food is in a sense *pushed* down and through the stomach. Ian’s motility doctor does not think that the bethanechol is helping with his emptying and he feels that the erythromycin is doing very little...... although, we will be holding onto the erythromycin for a while longer.


Here are two pictures of gastric emptying scans. The top of the images are the stomach and the lower portion are the intestines. These are not Ian’s scans, but appear in similar form.

Normal Gastric Emptying Scan

Abnormal Gastric Emptying Scan


3) Pylorospasms:

The pyloric valve empties the stomach. It is located at the base of the stomach and contracts to release digested food into the small intestines. It is another sphincter muscle. The contractions that release stomach contents, called chyme, are supposed to be regular in strength and frequency. There is some variability, but the contractions should be fairly regular. These muscle contractions are slightly altered after a fundoplcaition, as the stomach shape and emptying ability has been altered.  Ian has never had manometry testing to find this abnormality. His GI doctor knows something is off, but feels testing to prove it would be unnecessary. He feels that if need be, we would simply try an anti-spasmotic medication to help.

A pyloroplasty is a surgical procedure that cuts the pyloric valve and allows it to open more fully. Ian was never a candidate for this procedure because he has a history of dumping syndrome. Dumping syndrome is when the stomach contents leave the stomach all at one time (whether it be sooner or later). Part of Ian’s motility problems are that his stomach does not empty properly whenever it does empty. He could be having pylorospasms, dumping syndrome, and gastroparesis all at one time, They simply come in different patterns.

Ian is not taking an anti-spasmotic medication to help relax the pyloric valve. He is taking medications to create spasms for emptying (erythromycin and bethanechol) If we decide to try Levsin, this is an anti-spasmotic medication... The two, bethanechol and Levsin, cannot be taken at the same time because they effect the nervous system in two different ways. Bethanechol is a cholinergic and Levsin is an anti-cholinergic.

** See Nervous System description post **




4) Sensory:

It was once explained to me that internal and external sensory issues are connected. This was intriguing and I recalled some information about gut formation from my embryology class in school. As the embryo is forming, the outside turns in on itself. This inward turning forms the digestive “tube” as it is called. This means that the inside of our digestive tract is formed of the same “types” of cells as our skin. **They are not made of the same cells. ** They specialize into digestive cells. But, you can think of them as cells that come from the same “family” stem cell type.

While Ian has always had sensory issues, his digestive sensory issues have always been much more extreme. Ian’s external sensory issues have calmed down considerably thanks to occupational therapy, development, and simply time. Ian’s digestive sensory issues are currently managed by Neurontin and Periactin. The Neurontin helps him with visceral hyperalgesia...... increased pain of the organs. In Ian’s case, his digestive organs (stomach and intestines mostly). The Periactin helps by stimulating appetite.

The embryo has three layers: ectoderm, mesoderm, and endoderm. The ectoderm forms the skin, but also the lining of the mouth, throat, and rectum. The rest of the GI tract (esophagus, stomach and intestines) is formed by the endoderm. However, the endoderm cells are ectoderm cells that have migrated to the center as the embryo begins to turn inward. While they may be a bit confusing, I have included a couple pictures.




*** You can see in the “blastula” photo that the red begins to form as the blue caves in on itself. ***
*** The blue becomes the ectoderm (outer layer) and the red becomes the endoderm (inner layer). ***

*** Here again, the blue ectoderm turns inward to form the yellow endoderm. ***



Here are a few links that reference the topics above...




Stomach Diagram



4 comments:

  1. Thank you from a feeding therapist

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    1. You are very welcome! I feel honored that a feeding therapist finds my information valuable. Thank you for all you do!! :) Feeding therapists are so wonderful!!

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  2. I recently ran into your blogs and I find them so interesting as a parent of a FTT child. I'm intrugued by wanting to know more by askibg if you can break-down (no pun intended:) this article for me.

    ReplyDelete
    Replies
    1. Sure. Do you have a part that seems a little confusing that you would like me to break down some more? Or do you have some specific questions on how the information pertains to your individual situation? I would be happy to try and help.

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