INTRODUCTION: Gastroparesis, a common issue after lung transplantation may lead to severe gastrointestinal symptoms and erratic absorption of immunosuppressive medications. Treatment options for severe gastroparesis, refractory to conservative therapy, are limited. We present two cases of refractory gastroparesis after lung transplantation, whose symptoms improved with intra pyloric injection of botulinum toxin A (BoTx).
CASE PRESENTATION: Case 1: A 71 year old male presented 2 months post right lung transplant for COPD for evaluation of nausea, bloating and abdominal discomfort and erratic tacrolimus levels. Dietary modifications and addition of erythromycin had not improved his symptoms. The addition of metocloprimide was not tolerated secondary to extrapyramidal symptoms. A gastric emptying study demonstrated a solid food half-life of 367 minutes (normal 60–90 minutes) suggesting severe gastroparesis. An esophago-gastro-duodenoscopy (EGD) was performed to rule out mechanical obstruction (including pyloric stenosis) and presence of a bezoar and 50U of BoTx were injected at each quadrant of the pylorus for a total of 200U. Within 48 hrs, symptoms of bloating and early satiety improved and his immunosuppressive drug levels normalized. He was subsequently discharged home and had no recurrence of symptoms one year after his transplant. Case 2: Two months after bilateral lung transplant for COPD a 47 year old male developed a large gastric bezoar, which was removed endoscopically. Despite the removal of the bezoar and maximal medical therapy with erythromycin, metoclopromide, and domperidone he continued to have severe symptoms of bloating and erratic immunosuppressive levels. He had a repeat EGD to rule out bezoar reformation and underwent intra pyloric BoTx injections. Six weeks later patient had a follow up EGD and was noted to have residual food in the stomach and his gastric emptying time was 345 minutes. Repeat BoTx injections were done and post procedure his gastric emptying time improved to 263 minutes. One year later it remained stable at 244 minutes. Despite the persistent delay in his emptying time his symptoms improved and his immunosuppressive levels stabilized.
DISCUSSIONS: Gastroparesis results in delayed gastric emptying. After lung transplantation, severe gastroparesis causes debilitating symptoms and may lead to malnutrition and impaired drug absorption. In addition it is associated with increased risk of aspiration. Etiologies of gastroparesis after lung transplantation include vagal nerve injury during surgery and adverse effects of immunosuppressive medications. There is a paucity of information regarding the management of gastroparesis in transplant recipients. Current treatment is based on clinical experience with idiopathic and diabetic gastroparesis. Treatment options include dietary modifications (low residue diet) and use of prokinetic agents like metoclopramide, erythromycin, and domperidone. Novel treatment approaches for refractory cases include gastric electrical stimulation (GES), transcutaneuous electrical stimulation (TENS) and injection of intra pyloric BoTx. BoTx is thought to improve the gastric emptying time by relaxing the pyloric sphincter by inhibiting the excitatory transmitter substances to the pyloric muscle. Limitations of the BoTx injections to the pylorus include technical issues and potential for adverse events like hypersensitivity reactions and dysphagia. The safety and efficacy of intrapyloric BoTx injections in non-transplant patients have been published in several uncontrolled case series and to our knowledge this is the first published report on the safety and efficacy of BoTx injection in lung transplant recipients with gastroparesis. Given the increased incidence of severe gastroparesis after lung transplantation and the serious consequences, intrapyloric BoTx injection is justified in the most refractory cases after first line therapies and drug regimens have failed.
CONCLUSION: Intra pyloric injection of botulinum toxin may be justified and effective to treat the syndrome of functional gastric outlet obstruction in refractory gastroparesis after lung transplantation.
DISCLOSURE: Ravindra Gudavalli, No Financial Disclosure Information; No Product/Research Disclosure Information