Gastroparesis: Difference between revisions

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*More common in women, presumed due to elevated progesterone
*More common in women, presumed due to elevated progesterone
*Disease associated with reduced quality of life
*Disease associated with reduced quality of life
*Most commonly seen in diabetics, but other etiologies listed below
*Most commonly idiopathic but also commonly seen in diabetics
*Symptoms overlap with [[Functional Dyspepsia]]


==Causes of Non-Obstructive Delayed Gastric Emptying==
==Causes of Non-Obstructive Delayed Gastric Emptying==
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**[[Achalasia]]
**[[Achalasia]]
**Atrophic gastritis
**Atrophic gastritis
**Functional dyspepsia
**[[Functional Dyspepsia]]
**Hypertrophic [[Pyloric stenosis]]
**Hypertrophic [[Pyloric stenosis]]
**Celiac disease
**Celiac disease
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**Medication associated  
**Medication associated  
***Most commonly used: Opioid analgesics, anticholinergics, progesterone, PPIs, alcohol, tobacco
***Most commonly used: Opioid analgesics, anticholinergics, progesterone, PPIs, alcohol, tobacco
**Malignancy associated
**Ischemic gastroparesis


==Clinical Features==
==Clinical Features==
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**[[Cannabinoid hyperemesis syndrome]]
**[[Cannabinoid hyperemesis syndrome]]
*Infectious
*Infectious
**Bacterial toxins
**[[Spontaneous bacterial peritonitis]]
**[[Spontaneous bacterial peritonitis]]
**[[Urinary tract infection]
**[[Urinary tract infection]
**Viruses (adeno, norwalk, rota)
**Bacterial toxins, Viruses (adeno, norwalk, rota)
*Drugs/Toxins
*Drugs/Toxins
**Heavy metal poisoning
**Heavy metal poisoning
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**CT with oral and/or IV contrast to assess for intestinal obstruction
**CT with oral and/or IV contrast to assess for intestinal obstruction


===Complications===
==Treatment of Symptomatic [[Gastroparesis]]
*General principles include
**1. Correct fluid, electrolye, and nutritional deficiencies
**2. Identify and treat underlying cause if possible
**3. Reduce symptoms
*Important to review patient's medications, some medication may exacerbate symptoms
*Diabetic patient should have optimal glucose control
**[[Hyperglycemia]] alone can delay gastric emptying
*Dietary modifications
**Increase liquid nutrient component
**Minimize fat and fiber
**Smaller but more frequent meals
**Avoid carbonated beverages, [[alcohol]], and [[tobacco]]
*Medications:
**Anti-emetic agent- typical primary therapy
***[[Phenothiazines]] (dopamine receptor antagonists)
****[[Prochlorperazine]]
****Trimethobenzamide
****[[Promethazine]]
***[[Serotonin receptor antagonists]]
***[[Ondansetron]]
***Typically used only as needed
**Prokinetic agent
***Enhance gut contractility
***[[Metoclopramide]]
****Also anti-emetic actions
****Limited use to approximately 1 month
****Starting dose 10mg 30 minutes before meals and at bedtime
***[[Erythromycin]]
****Macrolide antibiotic has prokinetic actions
 
***Domperidone
 
*Refractory disease
**Nasogastric suction to decompress the stomach
 
==Complications==
*[[Acute Gastric Dilation]]
*[[Acute Gastric Dilation]]
*[[Esophagitis]]
*[[Esophagitis]]
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==Disposition==
==Disposition==
*Refractory disease may require hospitalization it:
**PO intolerance
**Pronounced dehydration requiring intravenous hydration
**Glycemic control
**Electrolyte correction


==See Also==
==See Also==

Revision as of 03:49, 6 January 2017

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 idiopathic but also commonly seen in diabetics
  • Symptoms overlap with Functional Dyspepsia

Causes of Non-Obstructive Delayed Gastric Emptying

  • Idiopathic
  • Diabetes mellitus
  • Postsurgical/Vagal nerve injury
  • GI disorders associated with delated gastric emptying
  • 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
    • Malignancy associated
    • Ischemic gastroparesis

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

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)
  • Consider:
    • 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
    • CT with oral and/or IV contrast to assess for intestinal obstruction

==Treatment of Symptomatic Gastroparesis

  • General principles include
    • 1. Correct fluid, electrolye, and nutritional deficiencies
    • 2. Identify and treat underlying cause if possible
    • 3. Reduce symptoms
  • Important to review patient's medications, some medication may exacerbate symptoms
  • Diabetic patient should have optimal glucose control
  • Dietary modifications
    • Increase liquid nutrient component
    • Minimize fat and fiber
    • Smaller but more frequent meals
    • Avoid carbonated beverages, alcohol, and tobacco
  • Medications:
      • Domperidone
  • Refractory disease
    • Nasogastric suction to decompress the stomach

Complications

Disposition

  • Refractory disease may require hospitalization it:
    • PO intolerance
    • Pronounced dehydration requiring intravenous hydration
    • Glycemic control
    • Electrolyte correction

See Also

External Links

References