Gastroparesis: Difference between revisions
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==Background== | ==Background== | ||
* | *Chronic GI disorder characterized by delayed gastric emptying ''without'' mechanical obstruction | ||
*More common in women | *More common in women, presumed due to elevated progesterone | ||
** | *Symptoms overlap with 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== | ||
* | *Variable symptoms | ||
*Early satiety, bloating, upper abdominal discomfort | |||
* | *[[Nausea/vomiting]] | ||
* | *[[Abdominal pain]] (''not'' predominant symptom) | ||
*[[Dehydration]], [[malnutrition]] if longstanding disease | |||
* | |||
==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
- 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, PPIs, 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
- Variable symptoms
- Early satiety, bloating, upper abdominal discomfort
- Nausea/vomiting
- Abdominal pain (not predominant symptom)
- Dehydration, malnutrition if longstanding disease
Differential Diagnosis
Nausea and vomiting
Critical
Emergent
- Acute radiation syndrome
- Acute gastric dilation
- Adrenal insufficiency
- Appendicitis
- Bowel obstruction/ileus
- Carbon monoxide poisoning
- Cholecystitis
- CNS tumor
- Electrolyte abnormalities
- Elevated ICP
- Gastric outlet obstruction, gastric volvulus
- Hyperemesis gravidarum
- Medication related
- Pancreatitis
- Peritonitis
- Ruptured viscus
- Testicular torsion/ovarian torsion
Nonemergent
- Acute gastroenteritis
- Biliary colic
- Cannabinoid hyperemesis syndrome
- Chemotherapy
- Cyclic vomiting syndrome
- ETOH
- Gastritis
- Gastroenteritis
- Gastroparesis
- Hepatitis
- Labyrinthitis
- Migraine
- Medication related
- Motion sickness
- Narcotic withdrawal
- Thyroid
- Pregnancy
- Peptic ulcer disease
- Renal colic
- UTI
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
- Infectious
- Drugs/Toxins
- Endocrine
- Diabetic ketoacidosis
- Thyroid disorder
- Parathyroid disorders
- Uremia
- Miscellaneous
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
- 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
- Metoclopramide
- Refractory disease:
- Nasogastric tube to decompress stomach
- Advanced therapies (not in ED) may include: placement of jejunostomy and/or gastrostomy tube, pyloric injection of botulinum toxin, [[Gastric pacemaker complication|gastric electric stimulation]
- Prevention of future exacerbations:
- Review medications, opioids, anticholinergics, PPIs 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
- 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.