Gastroparesis

Background

• Symptomatic chronic stomach disorder characterized by delayed gastric emptying without mechanical obstruction
• More common in women, presumed due to elevated progesterone
• Disease associated with reduced quality of life
• Most commonly seen in diabetics, but other etiologies listed below

Causes of Non-Obstructive Delayed Gastric Emptying

• Idiopathic
• Diabetes mellitus
• Postsurgical/Vagal nerve injury
• GI disorders associated with delated gastric emptying
  • GERD
  • Achalasia
  • Atrophic gastritis
  • Functional dyspepsia
  • Hypertrophic Pyloric stenosis
  • Celiac disease
• Non-GI disorders associated with delayed gastric emptying
  • Eating disorders: Anorexia nervosa
  • Neurologic disorders such as parkinson's
  • Collagen vascular disorders
  • Endocrine and metabolic disorders
    • Thyroid/Parathyroid dysfunction
    • Chronic renal insufficiency
  • Medication associated
    • Most commonly used: Opioid analgesics, anticholinergics, progesterone, PPIs, alcohol, tobacco

Clinical Features

• Symptons variable and include:
  • Early satiety
  • Nausea and vomiting
  • Bloating and upper abdominal discomfort
  • Abdominal pain (not predominant symptom)
• Signs, long standing disease:
  • Dehydration
  • Malnourishment

Differential Diagnosis

By organ system

• GI
  • Peptic ulcer disease
  • Mechanical Obstruction
    • Adhesion
    • Small bowel obstruction/LBO
    • Gastric outlet obstruction/Pyloric stenosis
    • Volvulus
    • Strangulated hernia
  • Pancreatitis
  • Appendicitis
  • Cholecystitis, Cholangitis
  • Acute Hepatitis
  • Inflammatory Bowel Disease
  • Intussusception
  • Malignancy
  • Mesenteric ischemia
  • Esophageal disorders (e.g. achalasia, GERD, esophagitis)
  • Functional disorders such as Irritable Bowel Syndrome
• Neurologic
  • Cannabinoid hyperemesis syndrome
• Infectious
  • Bacterial toxins
  • Spontaneous bacterial peritonitis
  • [[Urinary tract infection]
  • Viruses (adeno, norwalk, rota)
• Drugs/Toxins
  • Heavy metal poisoning
  • Methanol poisoning
• Endocrine
  • Diabetic ketoacidosis
  • Thyroid/parathyroid disorders
  • Uremia
• Miscellaneous
  • Anorexia nervosa, Bulemia

Evaluation

• Diagnosed by demonstrating delayed gastric emptying in a symptomatic patient after other etiologies are excluded
  • Gold standard to evaluate for delayed gastric emptying:
    • Gastric emptying scintigraphy of a solid-phase meal
      • Test quantifies the emptying of a physiologic caloric meal (0, 1, 2, and 4 hours post-prandial measurements)
  • Alternative tests assessing gastric emptying include:
    • Breath tests
    • Upper GI barium study
    • Ultrasound for serial changes in antral area
  • Abnormal gastric emptying suggests but does not prove that symptoms are caused by Gastroparesis

• • • • Disorder of gastric motor function not excluded in patients with normal gastric emptying
        • Regional dysfunctions of the stomach such as impaired fundic relaxation or gastric myoelectric dysrhythmias
    • Screen for secondary causes of Gastroparesis
      • Thyroid function tests
      • Rheumatologic serologies
      • HbA1C

Workup To Exclude Alternative Etiologies

• CBC
• Chem
• LFTs
• Lipase
• Coags
• Urinalysis
• Urine pregnancy (females)
• ?ECG (if >50 or at risk for cardiac disease)
• ?RUQ US
• ?Acute abdominal series including an upright CXR
  • Consider if at risk for perforated ulcer
• Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease
• Consider CT with oral and/or IV contrast to assess for intestinal obstruction

Complications

• Acute Gatstric Dilation
• Esophagitis
• Mallory Weiss Tear
• Bezoar
• Dehydration
• Malnutrition