Gastroparesis: Difference between revisions
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<translate>
==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>==
==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>==
*Chronic GI 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
*Symptoms overlap with functional dyspepsia
*Symptoms overlap with functional dyspepsia


===Causes of Non-Obstructive Delayed Gastric Emptying===
===Causes of Non-Obstructive Delayed Gastric Emptying===
*Idiopathic (most common)
*Idiopathic (most common)
*[[Diabetes mellitus]]
*[[Special:MyLanguage/Diabetes mellitus|Diabetes mellitus]]
*Postsurgical/Vagal nerve injury  
*Postsurgical/Vagal nerve injury  
*GI disorders associated with delayed emptying:
*GI disorders associated with delayed emptying:
**[[GERD]], [[Achalasia]]
**[[Special:MyLanguage/GERD|GERD]], [[Special:MyLanguage/Achalasia|Achalasia]]
**Atrophic [[gastritis]], celiac disease
**Atrophic [[Special:MyLanguage/gastritis|gastritis]], celiac disease
**Functional [[dyspepsia]]
**Functional [[Special:MyLanguage/dyspepsia|dyspepsia]]
**Hypertrophic [[pyloric stenosis]]
**Hypertrophic [[Special:MyLanguage/pyloric stenosis|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: [[Special:MyLanguage/opioids|opioids]], [[Special:MyLanguage/anticholinergics|anticholinergics]], [[Special:MyLanguage/PPI|PPI]]s, [[Special:MyLanguage/alcohol|alcohol]], tobacco, progesterone
**Eating disorders: [[Anorexia nervosa]]
**Eating disorders: [[Special:MyLanguage/Anorexia nervosa|Anorexia nervosa]]
**[[Parkinson's disease]] and other neurologic disorders  
**[[Special:MyLanguage/Parkinson's disease|Parkinson's disease]] and other neurologic disorders  
**[[Collagen vascular disease]]
**[[Special:MyLanguage/Collagen vascular disease|Collagen vascular disease]]
**Parathyroid/[[thyroid disorder]]
**Parathyroid/[[Special:MyLanguage/thyroid disorder|thyroid disorder]]
**Chronic renal insufficiency  
**Chronic renal insufficiency  
**Malignancy
**Malignancy
**Ischemic gastroparesis
**Ischemic gastroparesis


==Clinical Features==
==Clinical Features==
*Variable symptoms
*Variable symptoms
*Early satiety, bloating, upper abdominal discomfort
*Early satiety, bloating, upper abdominal discomfort
*[[Nausea/vomiting]]  
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]]  
*[[Abdominal pain]] (''not'' predominant symptom)
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]] (''not'' predominant symptom)
*[[Dehydration]], [[malnutrition]] if longstanding disease
*[[Special:MyLanguage/Dehydration|Dehydration]], [[Special:MyLanguage/malnutrition|malnutrition]] if longstanding disease
 


==Differential Diagnosis==
==Differential Diagnosis==
</translate>
{{Nausea and vomiting DDX}}
{{Nausea and vomiting DDX}}
<translate>
===Gastroparesis (by organ system)===
===Gastroparesis (by organ system)===
*GI
*GI
**[[Peptic ulcer disease]]
**[[Special:MyLanguage/Peptic ulcer disease|Peptic ulcer disease]]
**Mechanical Obstruction
**Mechanical Obstruction
***Adhesion
***Adhesion
***[[Small bowel obstruction]]/LBO
***[[Special:MyLanguage/Small bowel obstruction|Small bowel obstruction]]/LBO
***Gastric outlet obstruction/[[Pyloric stenosis]]
***Gastric outlet obstruction/[[Special:MyLanguage/Pyloric stenosis|Pyloric stenosis]]
***[[Volvulus]]
***[[Special:MyLanguage/Volvulus|Volvulus]]
***Strangulated [[hernia]]
***Strangulated [[Special:MyLanguage/hernia|hernia]]
**[[Pancreatitis]]
**[[Special:MyLanguage/Pancreatitis|Pancreatitis]]
**[[Appendicitis]]
**[[Special:MyLanguage/Appendicitis|Appendicitis]]
**[[Cholecystitis]], [[Cholangitis]]
**[[Special:MyLanguage/Cholecystitis|Cholecystitis]], [[Special:MyLanguage/Cholangitis|Cholangitis]]
**[[Acute Hepatitis]]
**[[Special:MyLanguage/Acute Hepatitis|Acute Hepatitis]]
**[[IBD]]
**[[Special:MyLanguage/IBD|IBD]]
**[[Intussusception]]
**[[Special:MyLanguage/Intussusception|Intussusception]]
**Malignancy  
**Malignancy  
**[[Mesenteric ischemia]]
**[[Special:MyLanguage/Mesenteric ischemia|Mesenteric ischemia]]
**Esophageal disorders (e.g. [[achalasia]], [[GERD]], [[esophagitis]])
**Esophageal disorders (e.g. [[Special:MyLanguage/achalasia|achalasia]], [[Special:MyLanguage/GERD|GERD]], [[Special:MyLanguage/esophagitis|esophagitis]])
**Functional disorders such as [[Irritable Bowel Syndrome]]
**Functional disorders such as [[Special:MyLanguage/Irritable Bowel Syndrome|Irritable Bowel Syndrome]]
*Neurologic
*Neurologic
**[[Cannabinoid hyperemesis syndrome]]
**[[Special:MyLanguage/Cannabinoid hyperemesis syndrome|Cannabinoid hyperemesis syndrome]]
*Infectious
*Infectious
**[[Spontaneous bacterial peritonitis]]
**[[Special:MyLanguage/Spontaneous bacterial peritonitis|Spontaneous bacterial peritonitis]]
**[[Urinary tract infection]]
**[[Special:MyLanguage/Urinary tract infection|Urinary tract infection]]
**[[bacterial disease|Bacterial]] toxins, [[viruses]] ([[adenovirus]], [[norovirus]], [[rotavirus]])
**[[Special:MyLanguage/bacterial disease|Bacterial]] toxins, [[Special:MyLanguage/viruses|viruses]] ([[Special:MyLanguage/adenovirus|adenovirus]], [[Special:MyLanguage/norovirus|norovirus]], [[Special:MyLanguage/rotavirus|rotavirus]])
*Drugs/Toxins
*Drugs/Toxins
**[[Heavy metal toxicity]]
**[[Special:MyLanguage/Heavy metal toxicity|Heavy metal toxicity]]
**[[Methanol toxicity]]
**[[Special:MyLanguage/Methanol toxicity|Methanol toxicity]]
*Endocrine
*Endocrine
**[[Diabetic ketoacidosis]]
**[[Special:MyLanguage/Diabetic ketoacidosis|Diabetic ketoacidosis]]
**[[Thyroid disorder]]
**[[Special:MyLanguage/Thyroid disorder|Thyroid disorder]]
**Parathyroid disorders
**Parathyroid disorders
**[[Uremia]]
**[[Special:MyLanguage/Uremia|Uremia]]
*Miscellaneous
*Miscellaneous
**[[Anorexia nervosa]], [[Bulimia nervosa]]
**[[Special:MyLanguage/Anorexia nervosa|Anorexia nervosa]], [[Special:MyLanguage/Bulimia nervosa|Bulimia nervosa]]
 


==Evaluation==
==Evaluation==
[[File:GastroparesisXray.jpg|thumb|Simple abdominal X-ray reveals a large amount of material in the stomach, suggesting severe gastric hypomotility.]]
[[File:GastroparesisXray.jpg|thumb|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
*Definitive diagnosis of gastroparesis not typically made in ED
**Gold standard is gastric emptying scintigraphy of a solid-phase meal
**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
**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]])
*ED workup to exclude alternative diagnoses and complications (e.g. [[Special:MyLanguage/dehydration|dehydration]], [[Special:MyLanguage/Electrolyte abnormalities|Electrolyte abnormalities]])
*CBC, BMP, [[LFTs]], lipase
*CBC, BMP, [[Special:MyLanguage/LFTs|LFTs]], lipase
*[[Urinalysis]], uHCG
*[[Special:MyLanguage/Urinalysis|Urinalysis]], uHCG
*Consider:  
*Consider:  
**[[ECG]] (if >50 or at risk for cardiac disease)
**[[Special:MyLanguage/ECG|ECG]] (if >50 or at risk for cardiac disease)
**[[RUQ US]]
**[[Special:MyLanguage/RUQ US|RUQ US]]
**[[Acute abdominal series]] including an upright CXR (if risk for perforated ulcer)
**[[Special:MyLanguage/Acute abdominal series|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


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


==Complications==
==Complications==
*[[Acute Gastric Dilation]]
 
*[[Esophagitis]], [[Mallory-Weiss tear]]
*[[Special:MyLanguage/Acute Gastric Dilation|Acute Gastric Dilation]]
*[[Bezoar]]
*[[Special:MyLanguage/Esophagitis|Esophagitis]], [[Special:MyLanguage/Mallory-Weiss tear|Mallory-Weiss tear]]
*[[Dehydration]], [[malnutrition]], [[electrolyte abnormalities]]
*[[Special:MyLanguage/Bezoar|Bezoar]]
*[[Special:MyLanguage/Dehydration|Dehydration]], [[Special:MyLanguage/malnutrition|malnutrition]], [[Special:MyLanguage/electrolyte abnormalities|electrolyte abnormalities]]
 


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


==See Also==
==See Also==
*[[Diabetes mellitus]]
 
*[[Nausea/vomiting]]
*[[Special:MyLanguage/Diabetes mellitus|Diabetes mellitus]]
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]]
 


==External Links==
==External Links==


==References==
==References==
<references/>
<references/>




[[Category:GI]]
[[Category:GI]]
</translate>

Latest revision as of 22:56, 4 January 2026


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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