Description

  • Gastroparesis is a disorder of abnormal gastric motility and delayed emptying in the absence of mechanical obstruction
  • Delayed gastric emptying defined as retention of >10% of gastric contents at 4 hours and/or >60% at 2 hours using standard low-fat meal
  • Most common causes:
    • Idiopathic in 36%
    • Diabetes mellitus in 29%
    • Postsurgical (vagotomy or vagus nerve damage) in 13%

Incidence/Prevalence

  • Age-adjusted incidence   
    • 2.4 per 100,000 person-years in men
    • 9.8 per 100,000 person-years in women
  • Age-adjusted prevalence per 100,000 persons
    • 9.6 per 100,000 in men
    • 37.8 per 100,000 women

Risk Factors

  • Female sex (female to male ratio 4:1)  
  • Young/middle-aged women (in idiopathic gastroparesis)
  • Diabetes mellitus
  • Medications
    • Opiates
    • Anticholinergics
    • Tricyclic antidepressants
    • Calcium channel blockers
    • Some diabetic medications
  • Substances  
    • Alcohol
    • Tobacco
    • Tetrahydrocannabinol (THC)
  • Viral infection (cytomegalovirus, Epstein-Barr virus, varicella zoster)
  • Nervous system disorders
    • Parkinson disease
    • Guillain-Barre syndrome
    • Systemic sclerosis
    • Multiple sclerosis (MS)
    • Dysautonomia
  • Autoimmune conditions
    • Scleroderma
    • Infiltrative enteritis
    • Amyloidosis
    • Eosinophilic gastroenteritis
    • Primary Sjogren syndrome
    • Ehlers-Danlos syndrome (EDS) type III
    • Myasthenia gravis
  • Hypothyroidism 
  • Paraneoplastic syndrome
  • Eating disorders (anorexia nervosa or bulimia)
  • Chronic mesenteric ischemia
  • Myopathy/muscular dystrophy, particularly
    • Myotonic dystrophy
    • Duchenne muscular dystrophy

Pathogenesis

  • Proposed mechanisms include loss of neuronal nitric oxide synthase (nNOS) expression and linked loss of interstitial cells of Cajal (ICC)
    • nNOS involved in
      • Smooth-muscle relaxation needed to accommodate fundus and relax pylorus
      • Peristaltic reflex of small intestine
      • Control of muscle tone of lower esophageal sphincter, pylorus, sphincter of Oddi, and anus
    • ICC involved in enabling phasic contraction
  • Delayed gastric emptying may also be a function of
    • Impaired antral contractions
    • Increased postprandial antral diameter (tone defect)
    • Altered distribution of intragastric contents
    • Pylorospasm
    • Abnormal postprandial jejunal burst contractions
    • Autonomic neuropathy

History

Chief Concern
  • Symptoms variable and may include
    • Nausea
    • Vomiting
    • Postprandial fullness
    • Early satiety
    • Bloating/upper abdominal pain
    • Heartburn/acid reflux
    • Anorexia
    • Weight loss
History of Present Illness (HPI)
  • Symptoms may be nonspecific
  • May mimic mechanical obstruction
  • Characteristics of vomiting episodes
    • Diabetic gastroparesis may present with more frequent vomiting than patients with idiopathic gastroparesis
    • True vomiting (commonly accompanied by nausea and retching) compared with effortless postprandial regurgitation (may indicate rumination syndrome)
    • Lower gastrointestinal symptoms in addition to vomiting may suggest alternative diagnosis such as constipation/rectal evacuation disorders
Past Medical History
  • Ask about history of
    • Connective tissue disorders, including
      • Scleroderma
      • Infiltrative enteritis
      • Amyloidosis
      • Eosinophilic gastroenteritis
      • Primary Sjogren syndrome
      • Ehlers-Danlos syndrome (EDS) type III
    • Autoimmune conditions
    • Paraneoplastic syndrome
    • Nervous system disorders
      • Parkinson disease
      • Guillain-Barre syndrome
      • Multiple sclerosis
      • Systemic sclerosis
      • Dysautonomia
    • Viral infection (cytomegalovirus, Epstein-Barr virus, or varicella zoster)
    • Stroke
    • Myopathy/muscular dystrophy
    • Surgery
      • Vagotomy or vagal injury
      • Fundoplication
      • Esophagectomy
      • Gastrectomy
      • Pancreatectomy
      • Roux-en-Y gastric bypass
      • Lung transplant
    • Eating disorders (anorexia nervosa or bulimia)
  • Ask about use of medications that contribute to delayed gastric emptying
  • Ask about alcohol, tobacco, and marijuana use  

Physical

General
  • Physical exam may be normal
  • Dehydration and evidence of malnutrition in severe cases  
  • Look for features of associated conditions, such as scleroderma
Abdomen
  • Auscultation for
    • Succussion splash
    • Absence of bowel sounds (may indicate ileus)
    • Louder, high-pitched sounds with tinkling quality (may indicate obstruction)
  • Palpate for mass, tenderness
Rectal
  • Assess for signs of constipation or rectal evacuation disorders such as
    • High-resting anal tone
    • Stool in rectum

Differential Diagnosis

  • Gastrointestinal disorders/conditions
    • Peptic ulcer disease 
    • Gastric outlet or small-bowel obstruction
    • Gastric/other malignancy
    • Dumping syndrome
    • Chronic pancreatitis
    • Helicobacter pylori infection
    • Small intestinal bacterial overgrowth (SIBO) syndrome
  • Functional dyspepsia
  • Gastroparesis-like syndrome (symptoms of gastroparesis in absence of delayed gastric emptying)
  • Median arcuate ligament syndrome (MALS)
  • Eating disorders (anorexia nervosa, bulimia nervosa)
  • Other causes of vomiting
    • Gastroesophageal reflux disease (GERD)
    • Rumination syndrome
    • Cannabinoid hyperemesis syndrome
    • Cyclic vomiting syndrome
    • Superior mesenteric artery syndrome

Making the Diagnosis

  • Diagnosis based on
    • Presence of symptoms of gastroparesis
    • Absence of gastric outlet obstruction or ulceration
    • Documented delay in gastric emptying
  • Testing
    • Gastric emptying scintigraphy (GES) of radiolabeled solid test meal at 4 hours is the standard for diagnosis
      • Radiolabeled low fat, egg-white meal (with toast, jam, and water) given to patient
      • Obtain GES images at 0 (immediately after meal), 1, 2, and 4 hours after ingestion and record percent remaining in stomach
      • Most accurate measurement is residual content at 4 hours (> 10% retention considered abnormal)
      • Grading severity of delay of gastric emptying at 4 hours
        • Grade 1 (mild) – 11%-20% retention  
        • Grade 2 (moderate) – 21%-35% retention  
        • Grade 3 (severe) – 36%-50% retention  
        • Grade 4 (very severe) – >50% retention  
  • Alternative testing   
    • Wireless capsule motility testing (WMC)
      • Alternative approach to evaluate gastric emptying, but requires further validation before being considered an alternative to GES
      • Real-time luminal readings of pH, pressure, and temperature during gastrointestinal transit
      • Time required for pill to be expelled from stomach into duodenum measured by monitoring acid levels (pH increases when pill enters duodenum)
    • Breath tests with carbon-13 (13C) – stable isotope breath tests with carbon-13 (13C) using octanoate or spirulina
  • Additional testing to rule out other conditions
    • Complete blood count (infection or malignancy)
    • Metabolic panel (diabetes or electrolyte imbalance) 
    • Thyroid tests (hypothyroidism)
    • Amylase (pancreatitis)
    • Pregnancy test, if appropriate

Management

  • Approach to management includes
    • Referral to dietician for counseling/education
    • Correcting fluid, electrolyte, and nutritional deficiencies 
    • Consideration of enteral alimentation if oral intake insufficient for nutrition/hydration
    • Identifying and correcting underlying cause of gastroparesis
    • Dietary modifications
    • Consideration of medications such as prokinetics and antiemetics
    • Tor patients with diabetes, achieving optimal glycemic control
  • Dietary modifications  
    • Eating small low-fat, low-fiber meals 4-5 times/day
    • Encouraging fluid intake throughout meals
    • Avoiding carbonated beverages
    • Avoiding alcohol and tobacco
  • Medications
    • Prokinetic agents may improve nausea, vomiting, and bloating (but not abdominal pain or early satiety)
      • Metoclopramide: first-line prokinetic agent, give at lowest effective dose to avoid possible extrapyramidal adverse events
      • IV erythromycin: in hospitalized patients needing IV prokinetic therapy;  long-term efficacy of oral erythromycin is limited by tachyphylaxis
      • Domperidone (Motilium): may reduce symptoms, improve gastric emptying  in patients with diabetes and gastroparesis 
    • Antiemetic medications 
      • Reduce symptoms of nausea and vomiting (does not alter gastric emptying)
      • Phenothiazines, antihistamines, or serotonin 5-HT3 receptor antagonists may be used alone or with prokinetics 
  • Optimizing diabetic management  
    • Glucose of >200mg/dL may delay gastric emptying
    • Glucagon-like peptide-1 (GLP-1) receptor agonists and pramlintide may delay gastric emptying; consider discontinuation of these agents before starting other treatments
  • Surgical procedures – usually reserved for patients refractory to medications
    • Consider venting gastrostomy
    • Jejunostomy for feeding
    • In select patients with profound/refractory gastric stasis, consider pyloroplasty or partial gastrectomy  
  • Consider acupuncture; may improve gastric motility and provide symptom relief 

Complications

  • Gastroesophageal reflux disease/Mallory-Weiss tear
  • Malnutrition
  • Electrolyte derangement
  • Bezoar
  • Small intestinal bacterial overgrowth (SIBO) syndrome

Kendra Church MS, PA-C, is a physician assistant at Dana-Farber Cancer Institute/Brigham & Women’s Hospital, and is also a senior clinical editor for DynaMed, an evidence-based, point-of-care database.

Sources

  1. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013;108(1):18-37. doi:10.1038/ajg.2012.373
  2. Liu N, Abell T. Gastroparesis updates on pathogenesis and management. Gut Liver. 2017;11(5):579-589. doi:10.5009/gnl16336
  3. Myint AS, Rieders B, Tashkandi M, Borum ML, Koh JM. Stephen S, Doman DB.Current and emerging therapeutic options for gastroparesis. Gastroenterol Hepatol (N Y). 2018;14(11):639-645.
  4. Loganathan P, Gajendran M, McCallum RW. Clinical manifestation and natural history of gastroparesis. Gastrointest Endosc Clin N Am. 2019 Jan;29(1):27-38. doi:10.1016/j.giec.2018.08.003 

Topics:

Diabetes Gastroenterology Gastrointestinal Illnesses