Hummel Michael, Geigenberger Gudrun, Brand Johann, Ziegler Anette-G, Füchtenbusch Martin
Klinik für Endokrinologie, Diabetologie und Suchtmedizin, Klinikum Schwabing, Städt. Klinikum München GmbH & Institut für Diabetesforschung, München.
Med Klin (Munich). 2008 Jul 15;103(7):514-8. doi: 10.1007/s00063-008-1075-2.
CASE HISTORY AND PHYSICAL EXAMINATION: A 24-year-old man with type 1 diabetes, nonresponding to standard treatment for severe gastroparesis, was admitted to hospital due to persisting nausea and vomiting. Further known complications included diabetic retinopathy, diabetic nephropathy with mild renal impairment, diabetic peripheral and cardiac autonomic neuropathy, and arterial hypertension.
Gastric motility parameters were evaluated by functional scintigraphy. Gastric emptying was severely delayed showing first appearance of food in duodenum after 25 min. After 60 min, technetium activity in the stomach was still detected in considerable amounts. The 50% emptying time was 58 min (normal time 10-20 min). A detailed symptom score for gastroparesis, prospectively investigated by a standardized patient diary, showed a severe and complex clinical disturbance: the frequency of daily attacks of impulsive vomiting ranged from 2 to 21 and the mean daily duration of nausea was 7.5 h. A value of 3.4 on the scale for a premature feeling of satiety (range 0-4, normal=0) was determined, as well as scores of 2.5 for symptoms of abdominal bloating (range 0-3, normal=0) and 3.7 for general well-being (range 0-4, normal=0).
Pharmacological interventions with antibiotics, prokinetics, antiemetics and, as a second step, percutaneous gastrostomy (first intervention) and jejunostomy (second intervention) were not long-term effective in reducing the clinical symptoms described above. Therefore, a single intrapyloric injection with 100 U of botulinum toxin was performed leading to a prompt and significant improvement of symptoms and an adequate oral nutrient intake the day after the procedure. Determined by gastric scintigraphy 1 week later, this led to a significant reduction of the 50% emptying time (36 min) and to an improvement of the symptom score for gastroparesis as determined 4 weeks later: frequency of daily attacks of impulsive vomiting ranged from 0 to 1, mean daily duration of nausea was 1 h, premature feeling of satiety (score 1.9), symptoms of abdominal bloating (1.1), and general well-being (2.1). The beneficial effect of the botulinum toxin injection was unchanged over 3 months, slightly diminishing by 4.5 months. After a second round of botulinum toxin injection, again, prompt relief of most of the symptoms was achieved. Percutaneous jejunostomy was then revised.
Intrapyloric injection of botulinum toxin is effective in improving the complex symptoms and clinical syndrome associated with diabetic gastroparesis resistant to conventional treatment. Upon waning of the therapeutic effect over time, the procedure can be repeated with success.
病例史及体格检查：一名24岁的1型糖尿病男性患者，对严重胃轻瘫的标准治疗无反应，因持续恶心和呕吐入院。其他已知并发症包括糖尿病视网膜病变、轻度肾功能损害的糖尿病肾病、糖尿病周围神经病变和心脏自主神经病变以及动脉高血压。
通过功能性闪烁扫描评估胃动力参数。胃排空严重延迟，食物在25分钟后首次出现在十二指肠。60分钟后，胃内仍检测到大量锝活性。50%排空时间为58分钟（正常时间为10 - 20分钟）。通过标准化患者日记前瞻性调查的胃轻瘫详细症状评分显示出严重且复杂的临床紊乱：冲动性呕吐的每日发作频率为2至21次，恶心的平均每日持续时间为7.5小时。饱腹感过早的量表评分为3.4（范围0 - 4，正常 = 0），腹胀症状评分为2.5（范围0 - 3，正常 = 0），总体健康评分为3.7（范围0 - 4，正常 = 0）。
使用抗生素、促动力药、止吐药进行药物干预，第二步进行经皮胃造口术（首次干预）和空肠造口术（第二次干预），在减轻上述临床症状方面并非长期有效。因此，进行了一次幽门内注射100 U肉毒杆菌毒素，术后第二天症状迅速且显著改善，口服营养摄入充足。1周后通过胃闪烁扫描测定，这导致50%排空时间显著缩短（36分钟），4周后测定的胃轻瘫症状评分有所改善：冲动性呕吐的每日发作频率为0至1次，恶心的平均每日持续时间为1小时，饱腹感过早（评分1.9），腹胀症状（1.1），总体健康（2.1）。肉毒杆菌毒素注射的有益效果在3个月内未变，4.5个月时略有减弱。第二轮肉毒杆菌毒素注射后，再次迅速缓解了大部分症状。然后对经皮空肠造口术进行了修正。
幽门内注射肉毒杆菌毒素可有效改善与常规治疗耐药的糖尿病胃轻瘫相关的复杂症状和临床综合征。随着治疗效果随时间减弱，该 procedure可成功重复进行。 （注：原文中“procedure”未明确中文释义，可根据上下文理解，这里暂保留英文）
