Gastroparesis: Difference between revisions
 
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==Background==
==Background<ref>Parkman HP, Hasler WL, Fisher RS. American Gastroenterlogical Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004; 127(5): 1592-1622.</ref>==
*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, presumed due to elevated progesterone
*More common in women, presumed due to elevated progesterone
*Disease associated with reduced quality of life
*Symptoms overlap with functional dyspepsia
*Most commonly idiopathic but also commonly seen in diabetics
*Symptoms overlap with [[Functional Dyspepsia]]


==Causes of Non-Obstructive Delayed Gastric Emptying==
===Causes of Non-Obstructive Delayed Gastric Emptying===
*Idiopathic
*Idiopathic (most common)
*[[Diabetes mellitus]]
*[[Diabetes mellitus]]
*Postsurgical/Vagal nerve injury  
*Postsurgical/Vagal nerve injury  
*GI disorders associated with delated gastric emptying
*GI disorders associated with delayed emptying:
**[[GERD]]
**[[GERD]], [[Achalasia]]
**[[Achalasia]]
**Atrophic [[gastritis]], celiac disease
**Atrophic gastritis
**Functional [[dyspepsia]]
**[[Functional Dyspepsia]]
**Hypertrophic [[pyloric stenosis]]
**Hypertrophic [[Pyloric stenosis]]
*Non-GI conditions/risk factors associated with delayed gastric emptying
**Celiac disease
**Medications: [[opioids]], [[anticholinergics]], [[PPI]]s, [[alcohol]], tobacco, progesterone
*Non-GI disorders associated with delayed gastric emptying
**Eating disorders: [[Anorexia nervosa]]
**Eating disorders: [[Anorexia nervosa]]
**Neurologic disorders such as parkinson's  
**[[Parkinson's disease]] and other neurologic disorders
**Collagen vascular disorders
**[[Collagen vascular disease]]
**Endocrine and metabolic disorders
**Parathyroid/[[thyroid disorder]]
***Thyroid/Parathyroid dysfunction
**Chronic renal insufficiency  
***Chronic renal insufficiency  
**Malignancy
**Medication associated
***Most commonly used: Opioid analgesics, anticholinergics, progesterone, PPIs, alcohol, tobacco
**Malignancy associated
**Ischemic gastroparesis
**Ischemic gastroparesis


==Clinical Features==
==Clinical Features==
*Symptons variable and include:
*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
*Signs, long standing disease:
**Dehydration
**Malnourishment


==Differential Diagnosis==
==Differential Diagnosis==
===By organ system===
{{Nausea and vomiting DDX}}
===Gastroparesis (by organ system)===
*GI
*GI
**[[Peptic ulcer disease]]
**[[Peptic ulcer disease]]
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***Gastric outlet obstruction/[[Pyloric stenosis]]
***Gastric outlet obstruction/[[Pyloric stenosis]]
***[[Volvulus]]
***[[Volvulus]]
***Strangulated hernia
***Strangulated [[hernia]]
**[[Pancreatitis]]
**[[Pancreatitis]]
**[[Appendicitis]]
**[[Appendicitis]]
**[[Cholecystitis]], [[Cholangitis]]
**[[Cholecystitis]], [[Cholangitis]]
**[[Acute Hepatitis]]
**[[Acute Hepatitis]]
**[[IBD]
**[[IBD]]
**[[Intussusception]]
**[[Intussusception]]
**Malignancy  
**Malignancy  
**[[Mesenteric ischemia]]
**[[Mesenteric ischemia]]
**Esophageal disorders (e.g. achalasia, GERD, [[esophagitis]])
**Esophageal disorders (e.g. [[achalasia]], [[GERD]], [[esophagitis]])
**Functional disorders such as [[Irritable Bowel Syndrome]]
**Functional disorders such as [[Irritable Bowel Syndrome]]
*Neurologic
*Neurologic
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**[[Spontaneous bacterial peritonitis]]
**[[Spontaneous bacterial peritonitis]]
**[[Urinary tract infection]]
**[[Urinary tract infection]]
**Bacterial toxins, Viruses (adeno, norwalk, rota)
**[[bacterial disease|Bacterial]] toxins, [[viruses]] ([[adenovirus]], [[norovirus]], [[rotavirus]])
*Drugs/Toxins
*Drugs/Toxins
**Heavy metal poisoning
**[[Heavy metal toxicity]]
**Methanol poisoning
**[[Methanol toxicity]]
*Endocrine
*Endocrine
**[[Diabetic ketoacidosis]]
**[[Diabetic ketoacidosis]]
**Thyroid/parathyroid disorders
**[[Thyroid disorder]]
**Parathyroid disorders
**[[Uremia]]
**[[Uremia]]
*Miscellaneous
*Miscellaneous
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==Evaluation==
==Evaluation==
*Diagnosed by demonstrating delayed gastric emptying in a symptomatic patient after other etiologies are excluded
[[File:GastroparesisXray.jpg|thumb|Simple abdominal X-ray reveals a large amount of material in the stomach, suggesting severe gastric hypomotility.]]
**Gold standard to evaluate for delayed gastric emptying:
*Definitive diagnosis of gastroparesis not typically made in ED
***Gastric emptying [[scintigraphy]] of a solid-phase meal  
**Gold standard is 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)
**Other studies assessing emptying: tests, upper GI barium study, ultrasound for changes in antral area
**Alternative tests assessing gastric emptying include:  
*ED workup to exclude alternative diagnoses and complications (e.g. [[dehydration]], [[Electrolyte abnormalities]])
***Breath tests
*CBC, BMP, [[LFTs]], lipase
***Upper GI barium study
*[[Urinalysis]], uHCG
***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:  
*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
**[[Acute abdominal series]] including an upright CXR (if risk for perforated ulcer)
***Consider if at 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  
**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]]==
==Management==
*General principles include
===ED Management===
**1. Correct fluid, electrolye, and nutritional deficiencies
*[[IVF]], [[Electrolyte repletion]]
**2. Identify and treat underlying cause if possible
*[[Antiemetics]]
**3. Reduce symptoms
**Dopamine receptor antagonists: [[Haloperidol]], [[Prochlorperazine]], [[promethazine]], trimethobenzamide
*Important to review patient's medications, some medication may exacerbate symptoms
***[[Haloperidol]] has been shown to reduce the rate of admission and morphine equivalent doses of analgesia<ref>Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017;35(8):1118-1120. doi:10.1016/j.ajem.2017.03.015</ref>
*Diabetic patient should have optimal glucose control
**[[Ondansetron]]
**[[Hyperglycemia]] alone can delay gastric emptying
*Prokinetic agents: enhance gut contractility
*Dietary modifications
**[[Metoclopramide]]
**Increase liquid nutrient component
***Also has antiemetic properties
**Minimize fat and fiber
***PRN and/or standing dose prior to meals and bedtime
**Smaller but more frequent meals
**[[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]]
**Avoid carbonated beverages, [[alcohol]], and [[tobacco]]
*Medications:
**Optimize glycemic control in patients with [[diabetes]] ([[hyperglycemia]] alone can delay gastric emptying)
**Anti-emetic agent- typical primary therapy
**Dietary: smaller but more frequent meals, minimize fat/fiber, increase liquid nutrient component
***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==
==Complications==
*[[Acute Gastric Dilation]]
*[[Acute Gastric Dilation]]
*[[Esophagitis]]
*[[Esophagitis]], [[Mallory-Weiss tear]]
*[[Mallory-Weiss tear]]
*[[Bezoar]]
*[[Bezoar]]
*Dehydration
*[[Dehydration]], [[malnutrition]], [[electrolyte abnormalities]]
*Malnutrition


==Disposition==
==Disposition==
*Refractory disease may require hospitalization if:  
*Discharge with outpatient follow up unless:
**PO intolerance
**Inability to tolerate PO
**Pronounced dehydration requiring intravenous hydration
**Need for ongoing IV rehydration, electrolyte correction, and/or glycemic control
**Glycemic control
**Electrolyte correction
*Outpatient management if none of the above and symptoms controlled


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


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

Latest revision as of 00:49, 1 February 2024

Background[1]

  • 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

Simple abdominal X-ray reveals a large amount of material in the stomach, suggesting severe gastric hypomotility.
  • 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.
  2. ↑ Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017;35(8):1118-1120. doi:10.1016/j.ajem.2017.03.015
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