What is the management approach for a patient with a history of GERD, status post fundoplication and G-POEM, presenting with intractable nausea and vomiting and bloody emesis?

Management of Intractable Nausea and Vomiting in a Patient with History of GERD, Fundoplication, and G-POEM

The patient requires urgent upper endoscopy with biopsies to evaluate the source of bleeding and assess for potential complications of prior surgeries, followed by appropriate targeted therapy based on endoscopic findings.

Initial Assessment and Diagnostic Approach

This 67-year-old female presents with a complex clinical picture of intractable nausea and vomiting with bloody emesis, with a history of:

• GERD status post fundoplication
• G-POEM (Gastric Per-Oral Endoscopic Myotomy)
• Multiple hospitalizations over the past 5 years

The presence of bloody emesis is particularly concerning and requires immediate evaluation. This presentation suggests potential complications from prior interventions or progression of underlying disease.

Key Diagnostic Steps:

1. Upper Endoscopy (EGD) with Biopsies

   • Essential for direct visualization of the esophageal and gastric mucosa 1
   • Allows assessment of:
     • Fundoplication integrity
     • Post-G-POEM anatomy
     • Source of bleeding
     • Presence of inflammation, ulceration, or other mucosal abnormalities

2. Additional Testing Based on Endoscopic Findings:

   • Combined pH/MII (Multichannel Intraluminal Impedance) testing to evaluate for acid and non-acid reflux 1
   • Gastric emptying study to assess for gastroparesis 1
   • High-resolution manometry to evaluate for motility disorders 1

Management Algorithm

1. Immediate Management of Bleeding

• If active bleeding is identified on endoscopy:
  • Endoscopic hemostasis techniques (bipolar electrocoagulation or argon plasma coagulation) 1
  • If endoscopic treatment fails, consider angiographic embolization 1
  • External beam radiation therapy for chronic blood loss if appropriate 1

2. Management Based on Endoscopic Findings

A. If Failed Fundoplication/Recurrent GERD:

• Pharmacological Management:

  • High-dose PPI therapy (twice daily) 1
  • Consider adding H2-receptor antagonists 1
  • Prokinetic agents if gastroparesis is present 1

• Surgical/Endoscopic Options (if medical management fails):

  • Revision of fundoplication 2
  • Consider transoral incisionless fundoplication (TIF) 3, 4
  • Magnetic sphincter augmentation in selected cases 1

B. If Post-G-POEM Complications:

• For Gastroparesis:

  • Dietary modifications (small, frequent meals, low-fat, low-fiber diet)
  • Prokinetic agents (metoclopramide, with awareness of black box warning) 1
  • Consider gastric electrical stimulation for severe cases 1

• For Outlet Obstruction:

  • Endoscopic balloon dilation 1
  • Consider self-expanding metal stents for severe cases 1

3. Management of Intractable Nausea and Vomiting

• First-line Antiemetics:

  • 5-HT3 receptor antagonists (ondansetron) 1, 5
  • Dopamine receptor antagonists (prochlorperazine, haloperidol, metoclopramide) 1
  • Consider combination therapy for refractory cases 1

• Second-line Options:

  • Add corticosteroids 1
  • Consider olanzapine 1
  • Benzodiazepines for anxiety-related nausea 1
  • Cannabinoids for refractory cases 1

• Nutritional Support:

  • IV hydration and electrolyte correction
  • Consider jejunal feeding tube for nutritional support if oral intake remains inadequate 1
  • Parenteral nutrition only if enteral feeding is not possible 1

Special Considerations

Post-Fundoplication Syndrome

Patients who have undergone fundoplication may experience a constellation of symptoms including retching, bloating, and feeding intolerance 6. Management includes:

• Smaller, more frequent meals
• Avoidance of carbonated beverages
• Proper positioning after meals
• Addressing potential iatrogenic causes of symptoms 6

Post-G-POEM Reflux

G-POEM can lead to new or worsened GERD symptoms in some patients. Recent evidence suggests that TIF may be effective in managing post-POEM GERD with 75% of patients able to discontinue or significantly reduce PPI use 3, 4.

Follow-up and Monitoring

• Close follow-up after initial management to assess symptom response
• Repeat endoscopy in 4-8 weeks if mucosal abnormalities were found
• Consider long-term PPI therapy if evidence of ongoing acid-related disease
• Regular nutritional assessment and support

Pitfalls to Avoid

1. Assuming symptoms are solely due to GERD - Consider other etiologies including gastroparesis, functional disorders, and mechanical complications from prior surgeries.

2. Overlooking medication side effects - Review all medications as potential contributors to symptoms.

3. Delaying endoscopic evaluation - The presence of bloody emesis warrants urgent endoscopic assessment.

4. Inadequate antiemetic therapy - Use combination therapy and around-the-clock dosing rather than as-needed administration for intractable symptoms 1.

5. Missing psychological factors - Consider psychological assessment and support, as chronic symptoms can have significant psychological impact.