Gastroparesis: Difference between revisions
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*GI disorders associated with delayed emptying: | *GI disorders associated with delayed emptying: | ||
**[[GERD]], [[Achalasia]] | **[[GERD]], [[Achalasia]] | ||
**Atrophic gastritis, celiac disease | **Atrophic [[gastritis]], celiac disease | ||
**Functional dyspepsia | **Functional [[dyspepsia]] | ||
**Hypertrophic [[ | **Hypertrophic [[pyloric stenosis]] | ||
*Non-GI conditions/risk factors associated with delayed gastric emptying | *Non-GI conditions/risk factors associated with delayed gastric emptying | ||
**Medications: [[opioids]], [[anticholinergics]], [[PPI]]s, [[alcohol]], tobacco, progesterone | **Medications: [[opioids]], [[anticholinergics]], [[PPI]]s, [[alcohol]], tobacco, progesterone | ||
| Line 40: | Line 40: | ||
***Gastric outlet obstruction/[[Pyloric stenosis]] | ***Gastric outlet obstruction/[[Pyloric stenosis]] | ||
***[[Volvulus]] | ***[[Volvulus]] | ||
***Strangulated hernia | ***Strangulated [[hernia]] | ||
**[[Pancreatitis]] | **[[Pancreatitis]] | ||
**[[Appendicitis]] | **[[Appendicitis]] | ||
| Line 56: | Line 56: | ||
**[[Spontaneous bacterial peritonitis]] | **[[Spontaneous bacterial peritonitis]] | ||
**[[Urinary tract infection]] | **[[Urinary tract infection]] | ||
**Bacterial toxins, | **[[bacterial disease|Bacterial]] toxins, [[viruses]] ([[adenovirus]], [[norovirus]], [[rotavirus]]) | ||
*Drugs/Toxins | *Drugs/Toxins | ||
**[[Heavy metal toxicity]] | **[[Heavy metal toxicity]] | ||
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*[[Urinalysis]], uHCG | *[[Urinalysis]], uHCG | ||
*Consider: | *Consider: | ||
**ECG (if >50 or at risk for cardiac disease) | **[[ECG]] (if >50 or at risk for cardiac disease) | ||
**[[RUQ US]] | **[[RUQ US]] | ||
**Acute abdominal series including an upright CXR (if risk for perforated ulcer) | **[[Acute abdominal series]] including an upright CXR (if risk for perforated ulcer) | ||
**CT abdomen/pelvis to rule out obstruction | **CT abdomen/pelvis to rule out obstruction | ||
**Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease | **Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease | ||
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.