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 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
  • Cannabinoid hyperemesis syndrome
• 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
  • Anorexia nervosa, Bulimia nervosa

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
  • 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 only used prn
  • 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 pro kinetic actions
      • Starting dose 125-350mg TID or QID
      • Similar efficacy as Metoclopramide
    • Other agents less commonly used
• Refractory disease
  • Nasogastric suction to decompress the stomach
  • Some patients respond better to alternative pro-kinetics than others
  • Dual therapy with both anti-emetic and pro-kinetic agents
    • Consider psychotropic medications
  • Placement of feeding jejunostomy and/or venting gastrostomy
  • Advanced/experimental therapies include:
    • Pyloric infection of botulinum toxin
    • Gastric electric stimulation
    • Alternative and unconventional medical therapies

Complications

• Acute Gastric Dilation
• Esophagitis
• Mallory-Weiss tear
• Bezoar
• Dehydration
• Malnutrition

Disposition

• Refractory disease may require hospitalization if:
  • PO intolerance
  • Pronounced dehydration requiring intravenous hydration
  • Glycemic control
  • Electrolyte correction
• Outpatient management if none of the above and symptoms controlled

See Also

• Diabetes mellitus

References

• 1. Parkman HP, Hasler WL, Fisher RS. American Gastroenterlogical Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004; 127(5): 1592-1622.