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 | *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 | **[[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 | ||
**[[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
- 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
- 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
- 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
- [[IBD]
- Intussusception
- Malignancy
- Mesenteric ischemia
- Esophageal disorders (e.g. achalasia, GERD, esophagitis)
- Functional disorders such as Irritable Bowel Syndrome
- Neurologic
- Infectious
- Spontaneous bacterial peritonitis
- [[Urinary tract infection]
- Bacterial toxins, Viruses (adeno, norwalk, rota)
- Drugs/Toxins
- Heavy metal poisoning
- Methanol poisoning
- Endocrine
- Diabetic ketoacidosis
- Thyroid/parathyroid disorders
- Uremia
- Miscellaneous
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)
- Gastric emptying scintigraphy of a solid-phase meal
- 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
- Gold standard to evaluate for delayed gastric emptying:
- 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
- Disorder of gastric motor function not excluded in patients with normal gastric emptying
- 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
- Hyperglycemia alone can delay gastric emptying
- Dietary modifications
- Medications:
- Anti-emetic agent- typical primary therapy
- Phenothiazines (dopamine receptor antagonists)
- Prochlorperazine
- Trimethobenzamide
- Promethazine
- Serotonin receptor antagonists
- Ondansetron
- Typically used only as needed
- Phenothiazines (dopamine receptor antagonists)
- 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
- Anti-emetic agent- typical primary therapy
- Domperidone
- Refractory disease
- Nasogastric suction to decompress the stomach
Complications
- Acute Gastric Dilation
- Esophagitis
- Mallory-Weiss tear
- Bezoar
- Dehydration
- Malnutrition
Disposition
- Refractory disease may require hospitalization it:
- PO intolerance
- Pronounced dehydration requiring intravenous hydration
- Glycemic control
- Electrolyte correction