Gastroparesis: Difference between revisions

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==Background==
==Background==
*Symptomatic chronic stomach disorder characterized by delayed gastric emptying without mechanical obstruction  
*Chronic GI disorder characterized by delayed gastric emptying ''without'' mechanical obstruction  
*More common in women
*More common in women, presumed due to elevated progesterone
**Gastric motility reduced by progesterone
*Symptoms overlap with functional dyspepsia
**Vs. Functional dyspepsia
 
===Causes of Non-Obstructive Delayed Gastric Emptying===
*Idiopathic (most common)
*[[Diabetes mellitus]]
*Postsurgical/Vagal nerve injury
*GI disorders associated with delayed emptying:
**[[GERD]], [[Achalasia]]
**Atrophic [[gastritis]], celiac disease
**Functional [[dyspepsia]]
**Hypertrophic [[pyloric stenosis]]
*Non-GI conditions/risk factors associated with delayed gastric emptying
**Medications: [[opioids]], [[anticholinergics]], [[PPI]]s, [[alcohol]], tobacco, progesterone
**Eating disorders: [[Anorexia nervosa]]
**[[Parkinson's disease]] and other neurologic disorders
**[[Collagen vascular disease]]
**Parathyroid/[[thyroid disorder]]
**Chronic renal insufficiency
**Malignancy
**Ischemic gastroparesis


==Clinical Features==
==Clinical Features==
*Symptons variable and including
*Variable symptoms
**Early satiety  
*Early satiety, bloating, upper abdominal discomfort
**Nausea and vomiting
*[[Nausea/vomiting]]
**Bloating and upper abdominal discomfort
*[[Abdominal pain]] (''not'' predominant symptom)
**Abdominal pain (not predominant symptom)
*[[Dehydration]], [[malnutrition]] if longstanding disease
*Functional dyspepsia- abdominal pain is the predominant symptom


==Differential Diagnosis==
==Differential Diagnosis==
{{Nausea and vomiting DDX}}
===Gastroparesis (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 disease|Bacterial]] toxins, [[viruses]] ([[adenovirus]], [[norovirus]], [[rotavirus]])
*Drugs/Toxins
**[[Heavy metal toxicity]]
**[[Methanol toxicity]]
*Endocrine
**[[Diabetic ketoacidosis]]
**[[Thyroid disorder]]
**Parathyroid disorders
**[[Uremia]]
*Miscellaneous
**[[Anorexia nervosa]], [[Bulimia nervosa]]


==Evaluation==
==Evaluation==
*Definitive diagnosis of gastroparesis not typically made in ED
**Gold standard is gastric emptying scintigraphy of a solid-phase meal
**Other studies assessing emptying: tests, upper GI barium study, ultrasound for changes in antral area
*ED workup to exclude alternative diagnoses and complications (e.g. [[dehydration]], [[Electrolyte abnormalities]])
*CBC, BMP, [[LFTs]], lipase
*[[Urinalysis]], uHCG
*Consider:
**[[ECG]] (if >50 or at risk for cardiac disease)
**[[RUQ US]]
**[[Acute abdominal series]] including an upright CXR (if risk for perforated ulcer)
**CT abdomen/pelvis to rule out obstruction
**Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease


==Management==
==Management==
===ED Management===
*[[IVF]], [[Electrolyte repletion]]
*[[Antiemetics]]
**Dopamine receptor antagonists: [[Prochlorperazine]], [[promethazine]], trimethobenzamide
**[[Ondansetron]]
*Prokinetic agents: enhance gut contractility
**[[Metoclopramide]]
***Also has antiemetic properties
***PRN and/or standing dose prior to meals and bedtime
**[[Erythromycin]] 125-350mg TID or QID
*Refractory disease:
**[[Nasogastric tube]] to decompress stomach
**Advanced therapies (not in ED) may include: placement of jejunostomy and/or [[G-tube complications|gastrostomy tube]], pyloric injection of botulinum toxin, [[Gastric pacemaker complication|gastric electric stimulation]
*Prevention of future exacerbations:
**Review medications,  [[opioids]], [[anticholinergics]], [[PPI]]s may worsen or trigger symptoms
**Avoid carbonated beverages, [[alcohol]], and [[tobacco]]
**Optimize glycemic control in patients with [[diabetes]] ([[hyperglycemia]] alone can delay gastric emptying)
**Dietary: smaller but more frequent meals, minimize fat/fiber, increase liquid nutrient component
==Complications==
*[[Acute Gastric Dilation]]
*[[Esophagitis]], [[Mallory-Weiss tear]]
*[[Bezoar]]
*[[Dehydration]], [[malnutrition]], [[electrolyte abnormalities]]


==Disposition==
==Disposition==
*Discharge with outpatient follow up unless:
**Inability to tolerate PO
**Need for ongoing IV rehydration, electrolyte correction, and/or glycemic control


==See Also==
==See Also==
*[[Diabetes mellitus]]
*[[Nausea/vomiting]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<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.
[[Category:GI]]

Revision as of 20:55, 29 September 2019

Background

  • Chronic GI disorder characterized by delayed gastric emptying without mechanical obstruction
  • More common in women, presumed due to elevated progesterone
  • Symptoms overlap with functional dyspepsia

Causes of Non-Obstructive Delayed Gastric Emptying

Clinical Features

Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

Gastroparesis (by organ system)

Evaluation

  • Definitive diagnosis of gastroparesis not typically made in ED
    • Gold standard is gastric emptying scintigraphy of a solid-phase meal
    • Other studies assessing emptying: tests, upper GI barium study, ultrasound for changes in antral area
  • ED workup to exclude alternative diagnoses and complications (e.g. dehydration, Electrolyte abnormalities)
  • CBC, BMP, LFTs, lipase
  • Urinalysis, uHCG
  • Consider:
    • ECG (if >50 or at risk for cardiac disease)
    • RUQ US
    • Acute abdominal series including an upright CXR (if risk for perforated ulcer)
    • CT abdomen/pelvis to rule out obstruction
    • Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease

Management

ED Management

Complications

Disposition

  • Discharge with outpatient follow up unless:
    • Inability to tolerate PO
    • Need for ongoing IV rehydration, electrolyte correction, and/or glycemic control

See Also

External Links

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.